Stimulation of the urinary system

ABSTRACT

Apparatus and methods are provided, including a bladder stimulator that includes an elongate element adapted to pass through a urethra or adapted to pass through another opening in the bladder, an expandable body coupled to said elongate element, and an array of one or more stimulator contacts coupled to the expandable body, the array including at least one contact adapted to contact a portion of a bladder of a subject when the expandable body is inserted in the bladder and expanded. A controller stimulates the portion of the bladder by driving a pulse into the bladder via the contact, the pulse having a frequency of 5 Hz-1 kHz. Other applications are also described.

CROSS-REFERENCES TO RELATED APPLICATIONS

The present application is a continuation-in-part of InternationalApplication PCT/IL2009/001163 to Bar-Yoseph, filed on 9 Dec. 2009, whichclaims the benefit of:

U.S. provisional application Ser. No. 61/120,901, filed on 9 Dec. 2008,

U.S. provisional application Ser. No. 61/173,228, filed on 28 Apr. 2009,

U.S. provisional application Ser. No. 61/180,957, filed on 26 May 2009,

U.S. provisional application Ser. No. 61/218,139, filed on 18 Jun. 2009,

U.S. provisional application Ser. No. 61/225,226, filed on 14 Jul. 2009,and

U.S. provisional application Ser. No. 61/233,500, filed on 13 Aug. 2009;and

the present application claims the benefit of U.S. provisionalapplication Ser. No. 61/355,522 to Bar-Yoseph, filed on Jun. 16, 2010.

The contents of all of the above-mentioned references are incorporatedby reference as if fully set forth herein.

FIELD OF THE INVENTION

Some embodiments of the present invention relate to control of humanphysiology and, more particularly, but not exclusively, to devices andmethods of controlling human physiology, such as kidney orcardiovascular function, by stimulation of the urinary system.

BACKGROUND Typical Anatomy of the Upper Urinary System

The kidneys are organs that have numerous biological roles. Theirprimary role is to maintain the homeostatic balance of bodily fluids byfiltering and secreting metabolites and minerals from the blood andexcreting them, along with water, as urine. The ureters are muscularducts that propel urine from the kidneys to the urinary bladder. In theadult, the ureters are usually 25-30 cm (10-12 inches) long.

The upper urinary system receives autonomic (mostly sympathetic)innervation, by the efferent nervous system. The sensory information isconveyed to the central nervous system (CNS) via the afferent nervoussystems. The two systems have different regional distribution; theefferent sympathetic innervation reaches all the segments of the renalvasculature and to a much lesser extent the tubular nephron. Theafferent sensory fibers are localized and predominate in the renalpelvis and ureter. The corticomedullary connective tissue contains bothtypes of innervation with a more prominent afferent innervation.

Congestive Heart Failure

Congestive heart failure (CHF) is a very common disorder, affecting 6million Americans and more than 22 million worldwide. CHF is a diseaseof the old; it is the leading hospital discharge diagnosis inindividuals aged 65 years or older. CHF is the number one reason forhospitalization in people 65 years or older in the United States,accounting for approximately 1 million hospitalizations annually. Thecost of hospitalizations for CHF is twice that for all forms of cancerand myocardial infarction combined. Treatment of heart failure costs anestimated $40 billion per year in the United States and nearly $80billion worldwide.

The Cardio-Renal Syndrome

Renal impairment is an independent and significant predictor ofmorbidity and mortality in CHF patients. Mortality increasesincrementally across the range of renal function, with 7% increased riskfor every 10-mL/min decrease in glomerular filtration rate (GFR). CHFtriggers kidney dysfunction by a pathological process dubbed thecardio-renal syndrome. The cardio-renal syndrome can be acute,characterized by a rapid decrease in cardiac output together withworsening renal function or chronic, in which gradual worsening of heartand/or kidney function develops over months.

The cardio-renal syndrome is a common condition; in the US, more than500,000 patients are admitted to hospital every year with acute heartfailure, and up 80% of these patients suffer from deteriorating renalfunctions. High renal sympathetic activity constitutes an important linkbetween CHF and renal dysfunction. Signals of shock and hypoperfusion,present in CHF patients, activate a number of compensation systems toincrease the blood pressure and prevent fluid losses. Of these, therenal sympathetic system is one of the most important ones; iteffectively reduces renal blood flow and kidney functions, includingsodium and water excretion to urine. In addition it activates therenin-angiotensin-aldosterone axis and therefore leads to hypertension,fluid retention and kidney dysfunction. It is now known that increasedrenal sympathetic drive is an independent factor in terms of progressivedeterioration of renal function and adverse outcome in CHF patients aswas shown by (Petersson et al., 2005).

The Current Treatment of CHF and the Cardio-Renal Syndrome

As of now, CHF is a progressive, incurable disease. Surgical treatmentoptions are few and are reserved for end-stage patients.

In patients with CHF and volume overload, initial therapy focuses onsalt and water restriction and diuretics. Diuretics improve symptoms andquality of life but do not necessarily prolong life. When patientsexperience persistent pulmonary congestion despite adequate diuretictreatment, they are defined as diuretic resistant. It is unadvised toincrease the dose of the diuretic as the potential negative side effectsoutweigh the possible benefit of fluid removal. One of the most seriousside effects of diuretic administration is activation of therenin-angiotensin-aldosterone axis and the sympathetic nervous systemthat leads to vasoconstriction and hypoperfusion.

Angiotensin-converting enzyme inhibitors (ACEI) and beta blockers areprescribed to most patients for control of hypertension and to reducecardiac remodeling. Although ACEI and adrenergic blockers areextensively used in these patients, these agents work on a systemiclevel. As such they cannot be used in an adequate dosage to selectivelyinhibit the pathological sympathetic renal drive.

Hypertension

Hypertension is one of the most common worldwide diseases afflictinghumans. In the US, forty-three million people are estimated to havehypertension, the age-adjusted prevalence of hypertension varying from18-32%. Because of the associated morbidity and mortality and the costto society, hypertension is an important public health challenge;hypertension is the most important modifiable risk factor for coronaryheart disease (which is the leading cause of death in North America),stroke (the third leading cause), congestive heart failure, end-stagerenal disease, and peripheral vascular disease.

Abnormal renal excretory function is one of the most importantmechanisms of the initiation and progression of hypertension. Variationsof arterial pressure signals the kidney to alter urinary sodium andwater excretion. On the long term, maintenance of sodium and waterbalance by the kidneys is believed to be primary in the long-termcontrol of arterial pressure. Thus, factors that decrease renalexcretory function lead to an increase in arterial pressure, which isrequired to reestablish and maintain sodium and water balance.

The dramatic positive effect of renal denervation on the development ofhypertension is evident in a wide variety of animal models in multiplespecies, suggesting that increased renal nerve activity may be a finalcommon pathway for the defect in renal sodium excretory ability requiredfor the development and maintenance of hypertension.

Chronic Kidney Disease

Chronic kidney disease (CKD) is a major cause of morbidity andmortality, particularly at the later stages. More than 400,000 patients(US) are on dialysis per year at an annual cost up to $67,000 for eachpatient. The 5-year survival rate for a patient undergoing chronicdialysis in the United States is approximately 35%. The most commoncause of death in the dialysis population is cardiovascular disease.

A large body of evidence indicates the presence of functionalabnormalities of the sympathetic nervous system in uremic animals andhumans. In patients with bilateral nephrectomy, the rate of sympatheticdischarge was lower than in patients with their native kidneys, and thisincreased rate was accompanied by lower mean arterial pressure andregional vascular resistance.

Sympathetic activation contributes to progressive kidney damage byelevation of blood pressure and by promoting atherosclerosis. Increasedsympathetic activity, progressive atherosclerosis and elevated bloodpressure contribute to the development of cardiac remodeling andfunctional alterations. These conditions are highly prevalent inpatients with CKD.

Current treatment aims for CKD are to halt the progression of the renaldamage by controlling the underlying condition that triggers the damage,i.e. hypertension and diabetes. Prescription of ACEI in such patientsshould take into account the potential influence of renal impairment onACEI metabolism, and adverse effects on the renal function itself(especially hypotension and acute reductions in glomerular filtrationrate which if untreated can escalate to acute renal failure).

Drugs that act on the sympathetic overactivity, such as alpha and betaadrenergic blockers are second or third line of treatment. These agentshave significant side effects; alpha blockers were recently shown toincrease the risk for stroke in patients with essential hypertension.Beta blockers are associated with intradyalitic hypotension.

As GFR decreases, diuretics are increasingly required for excretion ofthe daily water load. However, for a number of reasons diuretics becomerelatively ineffective in patients with a moderate to severe degree ofchronic kidney disease (creatinine clearance below approximately 35ml·min-1). Diuretics can lead to further rise in the serum creatinineand blood urea nitrogen concentrations and a high incidence ofhypokalemia and electrolyte disorders. Furthermore, net losses of sodiumand fluid during regular diuretic administration are limited bypostdiuretic renal sodium and fluid retention. Because of thesecomplications, diuretic use in the final stages of chronic kidneydisease, although desirable theoretically to maintain body water balanceis impractical because of the severe side effects

Acute Renal Failure

Causes of acute renal failure (ARF) can be broadly divided into threeclinical categories: a) Prerenal, which is an adaptive response tosevere volume depletion b) renal (or intrinsic), in response to kidneyinsult, including contrast material and c) postrenal.

Prerenal ARF is the most common cause of ARF. It often leads tointrinsic ARF if it is not promptly corrected. Acute reduction of renalblood flow (RBF), either because of blood loss or hypotension can resultin this syndrome. The hallmark of intrinsic ARF and the most common formis acute tubular injury (ATN). Prerenal ARF and ATN occur on a continuumof the same pathophysiological process and together account for 75% ofthe cases of ARF.

It cannot be overstated that the current treatment of ARF is mainlysupportive in nature and no therapeutic modalities to date have shownefficacy in treating the condition. Indications of immediate dialysistreatment include hyperkalemia not responsive to conventional treatment,pulmonary edema, and uremia.

Mortality rate estimates in ARF patients vary from 25-90%. Thein-hospital mortality rate is 40-50%; in intensive care settings, therate is 70-80%. The mortality in patients requiring dialysis is about50%. Mortality rates have changed little over the last two decades,reflecting the fact that there is no adequate treatment for thiscondition.

The following patents and publication may relate to stimulation of theurinary system. Their disclosures are incorporated herein by reference.Some embodiments of the invention use apparatus described therein and/orprocesses and/or physiological effects described therein, with theappropriate changes, and/or in combination with methods and/or apparatusdescribed herein, to provide functionality in accordance with someembodiments of the invention.

U.S. Patent Application Publications:

2005/0228459, 2005/0228460, 2005/0234523, 2005/0288730, 2006/0025821,2006/0041277, 2006/0116720, 2006/0142801, 2006/0206150, 2006/0212076,2006/0212078, 2006/0235474, 2006/0265014, 2006/0265015, 2006/0271111,2006/0276852, 2007/0066957, 2007/0083239, 2007/0112327, 2007/0129760,2007/0129761, 2007/0135875, 2007/0173899, 2007/0203549, 2007/0208382,2007/0265687, 2007/0282184, 2008/0119907, 2008/0213331, 2008/0255642,2009/0024195, 2009/0036948, 2009/0062873, 2009/0076409 and 2009/0221939.

U.S. Patents:

U.S. Pat. Nos. 5,749,845, 6,425,877, 6,500,158, 6,692,490, 6,699,216,6,743,197, 6,978,174, 7,162,303, 7,326,235, 7,617,005 and 7,620,451.

Non-U.S. Patents and Publications:

RU 2004103992/14, RU 2271840 C2, WO 97/44088 and WO 2004/075948.

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SUMMARY OF THE INVENTION

The present invention, in some embodiments of the invention relates tocontrolling kidney and/or body function by stimulation of the urinarysystem, particularly, but not only, using stimulation of urine transportsystems and/or afferent nerves. In some embodiments of the invention,the stimulation is specific enough to modulate and/or control naturalreflexes.

There is provided in accordance with an exemplary embodiment of theinvention, a bladder stimulator, comprising:

an elongate element adapted to pass through a urethra or adapted to passthrough another opening in the bladder;

an expandable body coupled to said elongate element at a couplinglocation; and

an array of one or more stimulator contacts mechanically coupled to saidexpandable body,

wherein said array includes at least one contact adapted to contact andselectively stimulate a trigone or a distal part of a ureter when saidexpandable body is inserted in a bladder and expanded.

In an exemplary embodiment of the invention, said expandable bodycomprises at least one arm carrying a contact and adapted to extend awayfrom said element. Optionally or alternatively, said array is configuredwith so that when it is anchored in place, said contact is in goodcontact with said trigone or distal ureter part. Optionally oralternatively, said expandable body comprises a balloon and wherein saidcoupling location is configured to lie at an exit from the bladder tothe urethra.

In an exemplary embodiment of the invention, said elongate elementcomprises a tube adapted to allow urine flow therethrough and isconfigured to substantially evacuate a bladder via an opening to a lumenof said tube, which opening is located at an expected location of aurethral entrance to the bladder.

In an exemplary embodiment of the invention, said expandable body isasymmetric in a manner that prevents rotation around said elongate bodywhen inserted in a bladder.

In an exemplary embodiment of the invention, said elongate body isselectively bendable when inserted.

In an exemplary embodiment of the invention, said array covers less thanone hemisphere of said expandable body.

In an exemplary embodiment of the invention, said array includes fewerthan 10 stimulator contacts.

In an exemplary embodiment of the invention, said array is sized so asto be able to stimulate two UVJs (ureter-vesico junctions) of a bladder,distanced between 2 and 5 cm from each other. Optionally, said arrayincludes at least one contact for each ureter.

In an exemplary embodiment of the invention, said contacts areelectrical contacts. Optionally or alternatively, said contacts areexpandable with said expandable body.

In an exemplary embodiment of the invention, the stimulator comprises atleast one lead extending along said element and adapted to extend out ofa body in which said catheter is inserted.

In an exemplary embodiment of the invention, the stimulator comprises anintegrated pulse generator for applying a pulse sequence to at least oneof said contacts.

In an exemplary embodiment of the invention, at least one of saidcontacts is a thermal stimulator contact.

In an exemplary embodiment of the invention, the stimulator comprises atleast one RF generator.

In an exemplary embodiment of the invention, at least one of saidcontacts is a chemical stimulator contact.

In an exemplary embodiment of the invention, said expandable bodydefines at least one channel for urine flow one or more of therethrough,underneath and thereby.

In an exemplary embodiment of the invention, said stimulator is concaveat a point matching a location of an enlarged prostate.

In an exemplary embodiment of the invention, said elongate element issoft enough and flexible enough to not interfere with a mobility of apatient when inserted in a urethra thereof.

In an exemplary embodiment of the invention, the stimulator comprises atleast one additional contact positioned and shaped to stimulate anon-trigone portion of the bladder.

In an exemplary embodiment of the invention, the stimulator comprises acontroller which stimulates said stimulator contact with a sequencesuitable for controlling one or more of a reno-renal reflex, avesico-vascular reflex, a cardiovascular function and a kidney function.Optionally, said controller includes a single manual control foradjusting an intensity of effect of said stimulation. Optionally oralternatively, said controller includes a feedback circuit to controlsaid stimulation, said feedback including one or both of feedback of aphysiological effect of said stimulation and feedback on a quality ofcontact between said stimulator contact and said trigone.

There is provided in accordance with an exemplary embodiment of theinvention, apparatus for stimulating the urinary system, comprising:

(a) a housing suitable for long term implantation of over 2 weeks;

(b) at least one stimulator coupled to said housing and adapted tostimulate a part of the urinary system which contains urine or anafferent nerve; and

(c) a controller within said housing configured to stimulate said atleast one stimulator with a stimulation sequence suitable to modify aphysiological functioning of a tissue that is not directly stimulated.Optionally, said stimulator is configured to be in contact with urine.Optionally or alternatively, said stimulator is configured to stimulatean afferent nerve.

In an exemplary embodiment of the invention, said stimulator isconfigured to stimulate a part of the urinary system which containsurine.

In an exemplary embodiment of the invention, said stimulator isconfigured with a stimulation sequence which affects a kidney functioneven when not applied directly to a nephron. Optionally oralternatively, said stimulator is configured with a stimulation sequencewhich affects a cardio-vascular function when applied to a urinarysystem. Optionally or alternatively, said stimulator is configured witha stimulation sequence which affects or modulates a renal reflex.Optionally, said reflex is one or both of a reno-renal reflex and avesico-vascular reflex.

In an exemplary embodiment of the invention, said stimulator isconfigured with a stimulation sequence suitable to affect the release ofa hormone.

In an exemplary embodiment of the invention, said stimulator isconfigured with a stimulation sequence suitable to modify thesensitivity of a sensory receptor or a nerve pathway thereof.

In an exemplary embodiment of the invention, said stimulator isconfigured with a stimulation sequence suitable to have a therapeuticeffect of ongoing change in physiological activity which lasts at least30 minutes after the sequence is stopped.

In an exemplary embodiment of the invention, said stimulator comprises achemical stimulator. Optionally, the apparatus comprises a chemicalreservoir for elution by said stimulator.

In an exemplary embodiment of the invention, said stimulator comprisesan electrical stimulator. Optionally, said stimulator includes a contactadapted to lie on an outside of a ureter. Optionally or alternatively,said stimulator includes a contact adapted to selectively electricallystimulate a trigone of a bladder. Optionally or alternatively, theapparatus comprises at least one insulation portion positioned to reduceelectrical leaks away of said stimulated part. Optionally oralternatively, the apparatus comprises at least one circuit configuredto ensure a quality of contact between said stimulator and tissue.Optionally or alternatively, said stimulator includes an elongate bodyadapted to lie within a ureter. Optionally or alternatively, saidstimulator is configured not to interfere mechanically with peristalsisor mobility of a ureter to which it applies stimulation.

In an exemplary embodiment of the invention, the apparatus comprises atleast one input for an input signal and wherein said control modifiessaid electrical stimulation in response to said input signal.Optionally, said controller has stored therein at least one target valuefor said input signal and wherein said modifying comprises modifying ina manner which approaches said target value. Optionally oralternatively, input signal is an input of an indication of aphysiological parameter. Optionally or alternatively, the apparatuscomprises a separate sensor which provides said input signal. Optionallyor alternatively, the apparatus comprises a physiological sensor whichprovides said input signal.

In an exemplary embodiment of the invention, said stimulation sequenceis set at an amplitude below a pain level.

In an exemplary embodiment of the invention, said stimulation sequenceincludes pauses of at least 1 hour and less than 10 hours.

In an exemplary embodiment of the invention, said functioning isselected from a group comprising: renal blood flow, GFR, diuresis,natriuresis, renal hormone secretion, blood pressure, vascularresistance, cardiac output, dyspnea level, body fluid balance and urineand plasma composition.

In an exemplary embodiment of the invention, said apparatus isfunctionally coupled to a stimulator which a portion of the body otherthan a urinary system.

In an exemplary embodiment of the invention, said stimulator is adaptedto screw into bladder tissue.

In an exemplary embodiment of the invention, said stimulator is adaptedto mount on the outside of a ureter.

There is provided in accordance with an exemplary embodiment of theinvention, apparatus for stimulating the urinary system, comprising:

(a) at least one stimulator adapted to stimulate a part of the urinarysystem;

(b) at least one input circuit configured to receive an input indicationindicating one or more of a kidney function and a cardio-vascularfunction; and

(c) a controller configured to stimulate said at least one stimulatorwith a stimulation sequence suitable to modify a function of one or bothof a kidney and a cardio-vascular system and also configured to receivean indication of said input indication from said at least one inputcircuit and modify said stimulation in response thereto. Optionally,said input comprises an outside input of a physiological parameter of apatient. Optionally, said input used by said controller comprises one ormore of an on/off command, a weight, a laboratory result and a feeling.

In an exemplary embodiment of the invention, said input comprises aphysiological sensor.

In an exemplary embodiment of the invention, said stimulator comprisesan electrical stimulator.

In an exemplary embodiment of the invention, said indication is anindication of one or more of a urinary tract function, a vascularfunction, a cardio-vascular function and a chemical property of thebody.

In an exemplary embodiment of the invention, said input circuitrycomprises a sensor comprising is one or more of an electrical sensor, animpedance sensor, a flow sensor, a pH sensor, an ion sensor, a pressuresensor, a heart rate sensor, a blood pressure sensor, a sensor ofperistalsis, a sensor of nerve activity, a urinary system pressuresensor and/or a thermal sensor.

In an exemplary embodiment of the invention, said controller activatessaid sequence over a period of treatment of at least 1 hour betweeninput indications.

In an exemplary embodiment of the invention, said controller activatessaid sequence over a period of treatment of less than 5 minutes betweeninput indications.

In an exemplary embodiment of the invention, said controller activatessaid sequence intermittently. Alternatively, said controller activatessaid sequence continuously.

In an exemplary embodiment of the invention, said sequence is appliedwith rest periods of at least 20 minutes between applications ofstimulation sequences.

In an exemplary embodiment of the invention, said sequence is appliedwith rest periods of at least 60 minutes and less than 12 hours betweenapplications.

In an exemplary embodiment of the invention, said controller spends atleast 80% of the time waiting for said input indication in order todetermine a next stimulation. In an exemplary embodiment of theinvention, said sequence is less than 20 minutes long.

In an exemplary embodiment of the invention, said sequence is configuredat a stimulation amplitude, shape and frequencies which avoid painand/or which avoid discomfort.

In an exemplary embodiment of the invention, said controller includes amemory having stored therein a table or a software linking desiredeffects and stimulation sequences which achieved such effects.

In an exemplary embodiment of the invention, said stimulation isneurostimulation suitable to modulate a reflex that modifies renalfunction.

In an exemplary embodiment of the invention, said stimulation issuitable to modulate a reflex that modifies a cardiovascular function.Optionally or alternatively, said reflex is a reno-renal reflex or avesico-vascular reflex.

In an exemplary embodiment of the invention, said controller isprogrammed to apply therapy for one or more of congestive heart failure(CHF), chronic kidney disease (CKD), acute renal failure (ARF),hypertension, contrast nephropathy, hepatorenal syndrome andcardio-renal syndrome.

In an exemplary embodiment of the invention, the apparatus comprises atleast an additional stimulator configured for control by said controllerfor additional and different stimulation of the body and wherein saidcontroller is programmed with at least one stimulation protocol directedat providing an effect utilizing said stimulation and said additionalstimulation. Optionally, said additional stimulation interacts with aneffect of said stimulation. Optionally or alternatively, said apparatuscontrols both a kidney function and a peristaltic pattern in the urinarysystem.

In an exemplary embodiment of the invention, said apparatus controlsboth a kidney function and a cardiovascular system parameter.

In an exemplary embodiment of the invention, said at least onestimulator is adapted to mount on one or more of an outside of theurinary system, a ureter, a nerve of the urinary system and a bladderand is selected from a group comprising a stimulator adapted to mountinside the urinary system; a stimulator which forms a part of a ureteralcatheter, a stimulator which forms a part of a urethral catheter; astimulator which forms a part of kidney piercing element; a stimulatorwhich is sized, shaped and adapted to dwell inside a bladder; astimulator including a controller which is encased in an implantablehousing; a stimulator including a controller which is configured forremaining outside a body.

In an exemplary embodiment of the invention, the apparatus comprises atissue ablation setting.

There is provided in accordance with an exemplary embodiment of theinvention, apparatus for stimulating the urinary system, comprising:

(a) at least one elongate element configured to lie within the ureter,allowing free urine flow within the ureter and configured to notinterfere with operation of ureter valves; and

(b) at least one stimulator element mechanically coupled to saidelongate element; and

(c) a controller configured to stimulate said at least one stimulatorelement with a stimulation sequence suitable to modify a function of atleast one kidney or a cardiovascular system. Optionally, said stimulatorelement comprises an electrical contact. Optionally, said stimulatorelement comprises an expandable element. Optionally, said stimulatorelement is configured to expand past a resting diameter of a ureter.

In an exemplary embodiment of the invention, said stimulator elementcomprises one or more of a mechanical stimulator; a chemical stimulatorand a thermal stimulator. Optionally or alternatively, said element isthin enough and soft enough to not interfere with operation of uretervalves.

In an exemplary embodiment of the invention, said stimulator contact isin the form of a tubular element of at least 3 mm in length mounted onan elongate element of at least 20 cm in length, which apparatus lodgesin a ureter or renal pelvis.

In an exemplary embodiment of the invention, said stimulator contact isin the form of a conical element that lodges in a renal pelvis.

In an exemplary embodiment of the invention, said elongate element isadapted for an insertion via a nephrostomic route.

There is provided in accordance with an exemplary embodiment of theinvention, apparatus for stimulating the urinary system, comprising:

(a) at least one non-electrical stimulator adapted to stimulate a partof the urinary system; and

(b) a controller configured to activate said at least one non-electrodestimulator in a manner suitable to affect an activity of said urinarysystem. Optionally, said controller modifies said activation in responseto feedback.

There is provided in accordance with an exemplary embodiment of theinvention, a stimulator adapted for urinary tract stimulation,comprising:

(a) an elongate body adapted to fit along the inside of a ureter from abladder to a kidney;

(b) a widening section at a distal end of said body, said wideningsection including at least one electrical contact.

There is provided in accordance with an exemplary embodiment of theinvention, a stimulator adapted for urinary tract stimulation,comprising:

(a) a coupling adapted to mount on the outside of a cylindrical body;

(b) a stimulator contact mounted on said coupling and adapted tostimulate a portion of the urinary system. Optionally, said coupling isconfigured to maintain a contact of said stimulator contact with saidcylindrical body over radial expansion of said body. Optionally oralternatively, said coupling is configured to allow axial deformation ofsaid cylindrical body.

There is provided in accordance with an exemplary embodiment of theinvention, a stimulator adapted for urinary tract stimulation,comprising:

(a) an elongate body adapted to fit along the inside of a ureter from abladder to at least 10 cm;

(b) a widening section formed on said body, said widening sectionincluding at least one electrical contact and said widening sectionconfigured to widen to at least a diameter of a ureter while allowingurine flow therepast. Optionally, said widening section includes aninflatable section.

There is provided in accordance with an exemplary embodiment of theinvention, a stimulator adapted for urinary tract stimulation,comprising:

(a) an elongate body adapted to pass through body tissue from a skin toa kidney;

(b) at least one electrical contact formed at a distal part of saidbody, wherein said distal part is configured to anchor in a kidneypelvis.

There is provided in accordance with an exemplary embodiment of theinvention, apparatus for stimulating the urinary system, comprising:

(a) at least one stimulator adapted to stimulate a part of the urinarysystem;

(b) at least one accelerometer; and

(c) a controller configured to stimulate said at least one stimulatorresponsive to an input signal from said accelerometer.

There is provided in accordance with an exemplary embodiment of theinvention, a method of controlling a physiological state, comprising:

(a) determining that it is desired to affect a functioning of a kidneyor other body system in a certain manner; and

(b) stimulating a urine carrying portion of the urinary system or anafferent nerve thereof in a manner which causes said effect on saidfunctioning of said kidney or other body system.

In an exemplary embodiment of the invention, determining comprisesdetermining a desired effect on a cardio-vascular system via an effecton a kidney function. Optionally or alternatively, determining comprisesdetermining a desired direct effect on a cardio-vascular system, not viaan effect on a kidney function. Optionally or alternatively, stimulatingmodulates the gain of the sympathetic drive to the kidney. Optionally oralternatively, said stimulating comprises exciting an afferent nerveinnervating the urinary system. Optionally or alternatively, saidstimulating comprises inhibiting an afferent nerve innervating theurinary system. Optionally or alternatively, said stimulating comprisesaffecting said kidney or other body system via the modulation ortriggering of at least one a nervous reflex. Optionally, said reflexcomprises one or both of a reno-renal reflex and a vesico-vascularreflex.

In an exemplary embodiment of the invention, said stimulating comprisesaffecting said kidney or other body system by providing at least twocompeting effects on said kidney or body system.

In an exemplary embodiment of the invention, said stimulating comprisesaffecting said kidney or said other body system via a hormonal effect.Optionally or alternatively, said stimulating comprises stimulating tohave an effect on said functioning for at least twice the length ofstimulation after said stimulating is completed. Optionally oralternatively, the method comprises also providing a systemic medicationwhich interacts with said stimulating.

In an exemplary embodiment of the invention, said stimulating comprisesstimulating in a manner which affects said kidney or said other bodysystem for at least 30 minutes after stimulation is stopped. Optionallyor alternatively, said stimulating comprises stimulating in a mannerwhich affects a cardio-vascular system for at least 30 minutes afterstimulation is stopped. Optionally or alternatively, said stimulatingcauses an increase in one or more of glomerular filtration rate, renalblood flow, diuresis and natriuresis by at least a factor of 1.1.Optionally, said factor is at least a factor of 2.

In an exemplary embodiment of the invention, said stimulating comprisesstimulating one or more of a ureter, a kidney pelvis, a trigone and abladder. Optionally or alternatively, said stimulating modulatesureteral or pyeloureteral peristalsis. Optionally or alternatively, saidstimulating modulates pressure within the urinary system. Optionally oralternatively, said stimulating comprises inserting a stimulator throughthe skin to a stimulation target. Optionally or alternatively, saidstimulating comprises implanting a stimulator. Optionally oralternatively, said stimulating comprises inserting a stimulator via aurethra. Optionally or alternatively, said stimulating comprisesstimulating via a stimulator that remains in said body for at least twoweeks. Optionally or alternatively, said stimulating comprisesstimulating via a stimulator that remains in said body for less than 2months. Optionally or alternatively, said stimulating comprisesstimulating as part of a treatment for one or more of acute heartfailure, congestive heart failure, hypertension, acute renal failure,chronic renal failure, hepato-renal syndrome, nephrotic syndrome,cardio-renal syndrome and myocardial infarct. Optionally oralternatively, said stimulating comprises stimulating for at least 2hours a day. Optionally or alternatively, said stimulating comprisesstimulating for less than 8 hours a day. Optionally or alternatively,said stimulating comprises stimulating using a same catheter as used formeasuring urine flow.

In an exemplary embodiment of the invention, said stimulating comprisesablating a portion of said urinary system in response to a measuredeffect of said stimulating.

In an exemplary embodiment of the invention, said stimulating comprisesminimally-invasively implanting a stimulator in contact with the urinarysystem.

There is provided in accordance with an exemplary embodiment of theinvention, a method of urinary system control, comprising:

(a) applying a first stimulation having an effect on a kidney functionor a cardiovascular system; and

(b) applying a second stimulation to the urinary system which interactswith said first stimulation. Optionally, said first stimulation is asystemic stimulation. Optionally or alternatively, said firststimulation is a provision of a medication.

There is provided in accordance with an exemplary embodiment of theinvention, a method of urinary system control, comprising stimulating aureter or a renal pelvis to modulate peristalsis therein for a period ofat least 1 hour to above normal peristalsis.

Optionally, said stimulation comprises electrical stimulation tooverpace peristaltic waves in said ureter. Optionally or alternatively,the method comprises collecting and measuring urine flow during saidstimulation and modifying said stimulation in view of a result of saidmeasurement.

There is provided in accordance with an exemplary embodiment of theinvention, a method of diagnosing a patient, comprising:

(a) stimulating a urinary tract of the patient;

(b) measuring a response of kidney function of cardiovascular functionto said stimulation; and

(c) diagnosing a pathology or physiological parameter in said patientbased on a result of said measurement. In an exemplary embodiment of theinvention, said pathology or physiological parameter is selected fromone or more of: receptor sensitivity, reflex damage, a kidney function,a cardio-vascular function, a urinary system function, blood analysisand kidney function availability. Optionally or alternatively, saidpathology or physiological parameter comprises determining a need forstimulation and further comprising providing a therapy over a period ofat least two weeks in response to said diagnosis.

There is provided in accordance with an exemplary embodiment of theinvention, an integrated urinary system stimulator adapted forstimulation of the bladder comprising a body having at least onestimulation contact formed thereon, a lead long enough to exit the bodyand an integrated control circuitry with a power source. Optionally, thesystem is less than 50 cm long and said lead is adapted to path througha urethra and allow urine flow. Optionally or alternatively, the systemis configured to be disposable after a single use. Optionally oralternatively, the system includes only a single control, for setting astimulation power. Optionally or alternatively, the system is configuredto apply a stimulation to a trigone area of the bladder, with a signalsuitable for activating a reno-renal reflex.

There is provided in accordance with an exemplary embodiment of theinvention, a urinary system stimulation system including a controlcircuitry, at least one lead extending from the control circuitry andadapted to attach to a bladder or a urethra, wherein the circuitry isset to activate one or both of a reno-renal reflex and a vesico-vascularreflex. Optionally, the control circuitry is adapted to close a feedbackloop using an input and maintain a value related to one or both ofkidney function and cardiovascular function within a desired range.Optionally or alternatively, the leads are configured to not interferewith motion of the ureter. Optionally or alternatively, the system isconfigured for operation of at least one year.

Unless otherwise defined, all technical and/or scientific terms usedherein have the same meaning as commonly understood by one of ordinaryskill in the art to which the invention pertains. Although methods andmaterials similar or equivalent to those described herein can be used inthe practice or testing of embodiments of the invention, exemplarymethods and/or materials are described below. In case of conflict, thepatent specification, including definitions, will control. In addition,the materials, methods, and examples are illustrative only and are notintended to be necessarily limiting.

Implementation of the method and/or system of embodiments of theinvention can involve performing or completing selected tasks manually,automatically, or a combination thereof. Moreover, according to actualinstrumentation and equipment of embodiments of the method and/or systemof the invention, several selected tasks could be implemented byhardware, by software or by firmware or by a combination thereof usingan operating system.

For example, hardware for performing selected tasks according toembodiments of the invention could be implemented as a chip or acircuit. As software, selected tasks according to embodiments of theinvention could be implemented as a plurality of software instructionsbeing executed by a computer using any suitable operating system. In anexemplary embodiment of the invention, one or more tasks according toexemplary embodiments of method and/or system as described herein areperformed by a data processor, such as a computing platform forexecuting a plurality of instructions. Optionally, the data processorincludes a volatile memory for storing instructions and/or data and/or anon-volatile storage, for example, a magnetic hard-disk and/or removablemedia, for storing instructions and/or data. Optionally, a networkconnection is provided as well. A display and/or a user input devicesuch as a keyboard or mouse are optionally provided as well.

There is therefore provided, in accordance with some applications of thepresent invention, apparatus including:

a bladder stimulator that includes:

-   -   an elongate element adapted to pass through a urethra or adapted        to pass through another opening in the bladder;    -   an expandable body coupled to said elongate element;    -   an array of one or more stimulator contacts coupled to said        expandable body, said array including at least one contact        adapted to contact a portion of a bladder of a subject when said        expandable body is inserted in the bladder and expanded; and    -   a controller configured to stimulate the portion of the bladder        by driving a pulse into the bladder via the contact, the pulse        having a frequency of 5 Hz-1 kHz.

For some applications, the controller is configured to drive the pulse,the pulse having an energy of between 0.00001 Joule and 0.1 Joule.

For some applications, the at least one contact is configured to contacta portion of the bladder selected from the group consisting of: atrigone, a ureter, a uretero-vesical junction, and a distal portion of aureter, and the controller is configured to stimulate the selectedportion of the bladder.

For some applications, the stimulator is configured to remain in asubject's body for three days to two weeks.

For some applications, the stimulator is configured to be implanted in asubject's body for at least two weeks.

For some applications, the controller is configured to stimulate theportion of the bladder for at least two hours a day.

For some applications, the controller is configured to stimulate anafferent nerve by driving the pulse.

For some applications, the controller is configured to modify thesensitivity of a sensory receptor or a nerve pathway thereof by drivingthe pulse.

For some applications, by driving the pulse, the controller isconfigured to modify a physiological functioning of a tissue that is notdirectly stimulated by the controller, said functioning being selectedfrom the group consisting of: renal blood flow, GFR, diuresis, and bloodpressure.

For some applications, the controller is configured to drive the pulseusing parameters that are such as to avoid causing pain to the subject.

For some applications, said elongate element includes a tube thatdefines a lumen and an opening to the lumen, and that is adapted toallow urine flow therethrough and is configured to substantiallyevacuate a bladder via the opening to the lumen of the tube.

For some applications, said array covers one hemisphere or less of saidexpandable body, and said array includes fewer than 10 stimulatorcontacts.

For some applications, said contact is expandable with said expandablebody.

For some applications, said contact includes conducting silicone.

For some applications, the stimulator is configured to measure urineflow through the elongate element.

For some applications, the controller is configured to drive the pulsewith a sequence suitable for controlling a function selected from thegroup consisting of: a reflex, a cardiovascular function and a kidneyfunction.

For some applications, the stimulator includes a single manual controlfor adjusting an intensity of effect of said stimulation.

For some applications, said elongate element is flexible.

For some applications, said elongate element is soft enough and flexibleenough to not interfere with a mobility of a patient when inserted in aurethra thereof.

For some applications, said stimulator is configured to facilitateplacement of the contact in contact with the portion of the subject'sbladder by being shaped to match a distortion of the bladder.

For some applications, said stimulator is concave at a point matching alocation of an enlarged prostate.

For some applications, said stimulator includes a protecting elementconfigured to prevent damage to a urethra by the contact duringinsertion of the contact through the urethra.

For some applications, said protecting element includes a coveringsheath.

For some applications, the stimulator includes a feedback circuit tocontrol said stimulation, said feedback including one or both offeedback of a physiological effect of said stimulation and feedback on aquality of contact between said stimulator contact and tissue of thesubject.

For some applications, the feedback circuit includes one or more of anelectrical sensor, a flow sensor and a pressure sensor.

There is further provided, in accordance with some applications of thepresent invention, apparatus including:

a bladder stimulator that includes:

-   -   a flexible elongate element adapted to pass through a urethra or        adapted to pass through another opening in the bladder;    -   an expandable body coupled to said elongate element;    -   an array of one or more stimulator contacts coupled to said        expandable body, said array including at least one contact        adapted to contact a portion of a bladder of a subject when said        expandable body is inserted in the bladder and expanded; and    -   a controller configured to stimulate the portion of the bladder        by driving a pulse into the bladder via the contact,    -   the flexible elongate element defining a lumen and an opening to        the lumen, and being adapted to allow urine flow therethrough        and to substantially evacuate the subject's bladder via the        opening to the lumen.

There is additionally provided, in accordance with some applications ofthe present invention, a method of controlling a physiological state ofa subject, including:

(a) determining that it is desired to affect functioning of a system ofthe subject selected from the group consisting of: a renal system and acardiovascular system; and

(b) in response thereto, affecting the functioning of the selectedsystem in the desired manner, by stimulating a urine carrying portion ofa urinary system of the subject.

For some applications, said stimulating includes modulating a gain of asympathetic drive to the kidney.

For some applications, said stimulating includes modulating activity ofan afferent nerve innervating the urinary system.

For some applications, said stimulating includes affecting thefunctioning of the selected system by performing an action selected fromthe group consisting of: activating and modulating, with respect to atleast one nervous reflex.

For some applications, the method further includes administeringsystemic medication to the subject, the stimulating being configured tointeract with the administration of the medication to the subject.

For some applications, said stimulating includes causing an increase byat least a factor of 1.1 in one or more parameters selected from thegroup consisting of: glomerular filtration rate, renal blood flow,diuresis, and natriuresis.

For some applications, said stimulating includes stimulating one or moreportions of the subject's body selected from the group consisting of: aureter, a trigone, a uretero-vesical junction, and a bladder.

For some applications, said stimulating includes stimulating via astimulator that remains in the subject's body for three days to twoweeks.

For some applications, said stimulating includes stimulating via astimulator that is implanted in the subject's body for at least twoweeks.

For some applications, said stimulating includes treating at leastpartially one or more conditions selected from the group consisting of:acute heart failure, congestive heart failure, hypertension, acute renalfailure, contrast nephropathy, chronic renal failure, shock, septicshock, nephrotic syndrome, cardio-renal syndrome and myocardial infarct.

For some applications, said stimulating includes stimulating for atleast 2 hours a day.

For some applications, said stimulating includes stimulating in such amanner that the functioning of the selected system is affected for atleast 30 minutes after stimulation is stopped.

For some applications, the method further includes receiving an inputduring the stimulation, and modifying a parameter of the stimulation inresponse thereto.

For some applications, the method further includes determining aphysiological parameter of the subject during the stimulation, andreceiving the input includes receiving an input that is indicative ofthe physiological parameter of the subject.

For some applications, determining the physiological parameter includesdetermining urine flow of the subject during the stimulation, andmodifying the parameter of the stimulation includes modifying theparameter of the stimulation in response to the determined urine flow.

BRIEF DESCRIPTION OF THE DRAWINGS

Some embodiments of the invention are herein described, by way ofexample only, with reference to the accompanying drawings. With specificreference now to the drawings in detail, it is stressed that theparticulars shown are by way of example and for purposes of illustrativediscussion of embodiments of the invention. In this regard, thedescription taken with the drawings makes apparent to those skilled inthe art how embodiments of the invention may be practiced.

In the drawings:

FIG. 1 is a flowchart of a method of controlling body physiology usingstimulation of the urinary system, in accordance with an exemplaryembodiment of the invention;

FIG. 2 is a schematic diagram of a urinary system showing exemplarytarget stimulation locations, in accordance with an exemplary embodimentof the invention;

FIG. 3 is a simplified schematic block diagram of a urinary systemstimulation system, in accordance with an exemplary embodiment of theinvention;

FIG. 4 is a more complete schematic block diagram of a urinary systemstimulation system, in accordance with an exemplary embodiment of theinvention;

FIG. 5 is a block diagram showing exemplary effects of stimulationaccording to some embodiments of the present invention, on body systems;

FIG. 6 illustrates an implantable stimulation system according to anexemplary embodiment of the invention;

FIG. 7 illustrates an external and ureter-dwelling stimulation systemaccording to an exemplary embodiment of the invention;

FIG. 8 illustrates a feedback process, according to an exemplaryembodiment of the invention;

FIG. 9A is a cross sectional view of female pelvic structures and anoptional transurethral insertion and the location of an intra-bladderstimulator connected to external stimulator controller, in accordancewith an exemplary embodiment of the invention;

FIG. 9B is a cross sectional view of female pelvic structures and anoptional suprapubic insertion and the location of an intra-bladderstimulator connected to external stimulator controller, in accordancewith an exemplary embodiment of the invention;

FIG. 9C is a cross sectional view of female pelvic structures and thelocation of an intra-bladder stimulator equipped with internalstimulator controller, in accordance with an exemplary embodiment of theinvention;

FIG. 10 is schematic block diagram of a feedback methodology, inaccordance with an exemplary embodiment of the invention;

FIG. 11 is a schematic block flow diagram of a method of selectingstimulation parameters, in accordance with an exemplary embodiment ofthe invention;

FIG. 12 illustrates an intra-bladder stimulator with recordedphysiological signals, in accordance with an exemplary embodiment of theinvention;

FIG. 13A-B illustrate physiological signals recorded from the bladder,using the system of FIG. 12, in accordance with an exemplary embodimentof the invention;

FIGS. 14A-C illustrate an intra-bladder stimulator designed forovercoming an enlarged prostate, in deployed and undeployed deviceconfigurations, in accordance with an exemplary embodiment of theinvention;

FIGS. 15A-B illustrate multi-electrode intra-bladder stimulator, inaccordance with exemplary embodiments of the invention;

FIGS. 16A-F illustrate an intra-bladder stimulator with extendingelectrodes, in accordance with an exemplary embodiment of the invention;

FIGS. 17A-C illustrate an asymmetric intra-bladder stimulator withextending electrodes, in accordance with an exemplary embodiment of theinvention;

FIGS. 18A-C illustrate an split-tip intra-bladder stimulator, inaccordance with an exemplary embodiment of the invention;

FIGS. 19A-C illustrate an intra-bladder stimulator with radiallyextending electrodes, in accordance with an exemplary embodiment of theinvention;

FIGS. 20A-C illustrate an intra-bladder stimulator with side-extendingelectrodes, in accordance with an exemplary embodiment of the invention;

FIG. 21 illustrates stimulators for stimulating a urinary system via apubic, vaginal and/or rectal approach, in accordance with an exemplaryembodiment of the invention;

FIGS. 22A-C shows an expanding in-bladder stimulator design, inaccordance with an exemplary embodiment of the invention;

FIG. 23 shows an expanding in-bladder stimulator design with a bendingshaft, in a prolapsed female, in accordance with an exemplary embodimentof the invention;

FIGS. 24 an expanding in-bladder stimulator design with a concavityimplanted in a male with an enlarged prostate, in accordance withexemplary embodiments of the invention;

FIGS. 25A-B are cross-sectional views of a lead in accordance with anexemplary embodiment of the invention;

FIG. 26 illustrates an intraluminal stimulator, in accordance with anexemplary embodiment of the invention;

FIG. 27A illustrates an intra-ureteral stimulator, in accordance with anexemplary embodiment of the invention;

FIG. 27B illustrates the stimulator of FIG. 27A, inserted in a ureter,in accordance with an exemplary embodiment of the invention;

FIG. 27C illustrates the stimulator of FIG. 27A, inserted in a ureter,in accordance with an alternative exemplary embodiment of the invention;

FIGS. 28A-28C3 illustrate designs for a stimulator including contactsand/or anchoring in the kidney pelvis in accordance with exemplaryembodiments of the invention.

FIG. 29A illustrates an intra-luminal stimulator with medial electricalcontacts, according to an exemplary embodiment of the invention;

FIGS. 29B1-29D2 illustrate medial contact designs in accordance with anexemplary embodiment of the invention;

FIGS. 30A-30D2 show exemplary intra-luminal stimulators having a thinbody, in accordance with an exemplary embodiment of the invention;

FIG. 31A-E show intra-luminal stimulators having balloon-expandableelectrical contacts, in accordance with exemplary embodiments of theinvention.

FIGS. 32A-C illustrate a stimulator adapted for extraluminal mounting ona tubular physiological structure, optionally such as a ureter, inaccordance with an exemplary embodiment of the invention;

FIG. 33A illustrates an extraluminal stimulator with patch contacts, inaccordance with an exemplary embodiment of the invention;

FIG. 33B-C illustrate an extraluminal stimulator with cuff contacts, inaccordance with an exemplary embodiment of the invention;

FIGS. 34A-B illustrate an extraluminal stimulator with diametermatching, in accordance with an exemplary embodiment of the invention;

FIG. 35 illustrates a stimulator with both extra-luminal andintraluminal components, according to an exemplary embodiment of theinvention.

FIGS. 36A-36E illustrate an implanted wireless stimulator andextracorporeal power sources therefore, according to exemplaryembodiments of the invention;

FIG. 37 shows an exemplary implantation of a stimulation system using anephrostomic approach, in accordance with an exemplary embodiment of theinvention;

FIG. 38 illustrates a stimulation device that is located within therenal pelvis, in accordance with an exemplary embodiment of theinvention;

FIG. 39 illustrates a stimulation device that is located within therenal pelvis, the ureter and the bladder, in accordance with anexemplary embodiment of the invention;

FIGS. 40A1-40B3 illustrate an exemplary nephrostomic stimulation deviceand cross-sections thereof, in accordance with an exemplary embodimentof the invention;

FIGS. 41A-B illustrate exemplary implantation locations for anephrostomic stimulation device, according to an exemplary embodiment ofthe invention;

FIGS. 41C1-41C3 illustrate stimulator designs, according to an exemplaryembodiment of the invention;

FIG. 42A illustrates an exemplary implantation location for anephrostomic stimulation device, according to an exemplary embodiment ofthe invention;

FIGS. 42B-42C2 illustrate exemplary anchoring mechanisms for anephrostomic stimulation device, according to an exemplary embodiment ofthe invention;

FIG. 43 illustrates a transcutaneous stimulator system andstimulation-transducing device, in accordance with an exemplaryembodiment of the invention;

FIG. 44A illustrates a stimulator having one or more conducting surfacescoupled to one or both of a kidney and a ureter, in accordance with anexemplary embodiment of the invention;

FIG. 44B illustrates an alternative stimulator having one or moreconducting surfaces coupled to one or both of a kidney and a ureter, inaccordance with an exemplary embodiment of the invention;

FIG. 45 illustrates urine flow collections from a single animal from thestimulated kidney (left) and the contralateral kidney (middle) togetherwith total urine flow (right), show stable basal urine flow (two leftcolumns in each plot), that sharply increases during stimulation (grey)and remains elevated for at least half an hour thereafter;

FIG. 46 illustrates GFR analysis from the same animal as above, showingincreased bilateral GFR during and following ureteral stimulation;

FIG. 47 illustrates RBF analysis from the same animal as above, showingincreased bilateral RBF during and following ureteral stimulation;

FIG. 48 illustrates the ratio of change in bilateral urine flow, GFR andRBF during ureteral nerve stimulation in relation to controlmeasurements (n=8);

FIGS. 49A-B illustrate two examples of single kidney urine flow, asmeasured in a ureter catheter. In the left example, stimulation of theureter for one minute sharply increased urine flow, the effect lastingafter discontinuation of the stimulation. In the right example ureteralstimulation transiently increased urine flow, without the long termeffect;

FIG. 50 illustrates the mean arterial pressure (MAP) measurement duringelectrical stimulation of the ureter. After an initial drop the MAPstabilizes to near the control values;

FIG. 51 illustrates Urine flow, GFR, and RBF before, during andfollowing ureteral stimulation in a sheep, showing that stimulation ofthe ureter significantly improved all these parameters, in accordancewith some embodiments of the invention;

FIG. 52 illustrates Urine flow and GFR for a control and during a 24 hureter stimulation in a sheep, showing that stimulation of the ureterincreased urine flow and GFR during a prolonged stimulation session, inaccordance with some embodiments of the invention;

FIGS. 53A1-53B3 are a set of charts showing the effect of intra-bladderstimulation on urine flow, GFR and sodium excretion;

FIG. 54 is a set of charts showing the effect of 360 degreesintra-bladder stimulation on urine flow, GFR and sodium excretion;

FIGS. 55A-B illustrate a double balloon bladder catheter with electricalcontacts, in accordance with some applications of the present invention;

FIGS. 56A-B illustrate an inflated and deflated front view of a doubleballoon bladder catheter with an array of electrical contacts, inaccordance with some applications of the present invention;

FIG. 57 illustrates a side view of the double balloon bladder catheterof FIG. 55, the double balloon having been inflated to a largerinflation volume than shown in FIG. 55, thereby causing greater bendingof the catheter than that shown in FIG. 55, in accordance with someapplications of the present invention;

FIG. 58 illustrates a double balloon bladder catheter placed in thebladder of a male subject that has an enlarged prostate, in accordancewith some applications of the present invention;

FIG. 59 illustrates a double balloon bladder catheter placed in thebladder of a female subject that has a cystocele, in accordance withsome applications of the present invention;

FIGS. 60A-B illustrate side views of the inflatable portion of thedouble balloon bladder catheter shown in FIG. 55, in accordance withsome applications of the present invention;

FIGS. 61A-C illustrate respective cross-sectional views of theinflatable portion of double balloon bladder catheter shown in FIG. 60,in accordance with some applications of the present invention;

FIGS. 62A-C illustrate cross-sectional views of the inflatable portionof a double balloon bladder catheter having electrical contacts that arecovered during insertion of the catheter into the bladder, at respectivestages of the inflation of the double balloon, in accordance with someapplications of the present invention;

FIG. 63 illustrates a side view of the inflatable portion of a doubleballoon bladder catheter, in accordance with some applications of thepresent invention;

FIGS. 64A-D illustrate cross-sectional views of the inflatable portionof the double balloon bladder catheter of FIG. 63, in accordance withsome applications of the present invention;

FIGS. 65A-C illustrate a bladder catheter that includes a balloon andelectrical contacts at a distal portion thereof, the flexibility of theballoon varying between respective locations of the balloon, inaccordance with some applications of the present invention;

FIGS. 66A-B illustrate a bladder catheter that includes a balloon andelectrical contacts at a distal portion thereof, the inflation of theballoon being controlled by internal strings, in accordance with someapplications of the present invention;

FIGS. 67A-B illustrate a bladder catheter with electrical contacts, thebending of the catheter being controlled by strings, in accordance withsome applications of the present invention.

DESCRIPTION OF EXEMPLARY EMBODIMENTS

Overview

The present invention, in some embodiments thereof, relates to a methodof controlling body functions using stimulation of the urinary system.

A broad aspect of some embodiments of the invention relates tocontrolling body functions by stimulating the urinary system. In anexemplary embodiment of the invention, the body functions are kidneyfunctions such as glomerular filtration rate (GFR), urine flow rate,urine composition, urine density and renal hormone secretion. Optionallyor alternatively, the body functions are cardiovascular functions, suchas blood pressure, portal pressure, pulmonary pressure, organ (includingrenal) blood flow, cardiac output, heart rate, intravascular andextravascular fluid volume, pulmonary and body edema levels. Optionallyor alternatively, the functions are bodywide systems such as bloodchemistry or sympathetic nerve activity. In some embodiments, bodyfunctions are affected by modifying kidney function. In an exemplaryembodiment of the invention, kidney function is modified by controllinga renal reflex, for example, the reno-renal reflex, or thevesico-vascular reflex. Optionally, kidney function is modified bychanging a peristalsis (e.g., by overpacing, with sensing of self-pacingor at an enforced frequency) of one or both ureters, possibly suchstimulation modulating a reno-renal reflex mediated by the ureter and/orby affecting urine pressure in the kidney. In an exemplary embodiment ofthe invention, the parts of the urinary system stimulated are partswhich are adapted to carry urine, such as the kidney pelvis, the ureterand/or the bladder. Optionally, the stimulated part comprises afferentnerves which are affected by the stimulation. Optionally, stimulation inaccordance with an exemplary embodiment of the invention is used,optionally with other treatment, such as medication or stimulation ofother parts of the body, affect, for example, to control, to compensate,force, manage, modulate and/or stand-in for natural body feedbackcycles; damaged and/or healthy such cycles. Optionally, the stimulationand/or control of body physiology are used as a long term treatment,optionally with a goal of treating, preventing degradation and/ormaintaining a patient.

Various embodiments of the invention are based on the inventors'surprising discovery that stimulation of the urinary system can affectkidney function and/or other bodywide functions, rather than merelyaffecting local function such as peristalsis or bladder voiding. Inparticular, the inventors have discovered that stimulating the bladder,bladder trigone, the ureters, as well as other parts of the urinarysystem affect kidney and/or other body functions, including functionsnot directly related to urinary such as cardiovascular functions, forexample blood pressure. It is believed, but this need not limit thescope of the invention, that such stimulation latches onto existingfeedback cycles in the body, possibly by affect the source of feedbacksignals (e.g., the afferent nerves), or by causing activity of thestimulated portions which then modulates existing reflex feedbackcycles.

In an exemplary embodiment of the invention, the stimulation iselectrical. However, in other embodiments of the invention, othersimulation methods may be used instead or in addition, for example,chemical stimulation, thermal stimulation and/or mechanical stimulation.In particular, ureter receptors may be stimulated by providing sodiumions therein.

In an exemplary embodiment of the invention, an implanted device is usedfor stimulating the urinary system. Alternatively or additionally, thedevice includes a trans-urethraly or transcutanesouly insertedstimulator, which may, optionally, extend out of the urethra to anexternal stimulator controller and/or power source. Optionally, thedevice includes a stimulator inside the bladder, inside the kidneyand/or inside the ureter. Optionally, the device operates by expandingthe ureter.

In an exemplary embodiment of the invention, an intra-ureteralstimulator is made thin and/or soft enough so it allows urine flow pastit and/or does not interfere with valves of the urinary tract.Optionally, such a stimulator is equipped with an anchoring mechanism,such as for example, such a stimulator ends in a curved element, forexample a pig tail at one or both sides or alternatively in a wideningform, for example, radially extending arms or a conical coil, whichlodges in the urinary system, for example, in the kidney pelvis and/orbladder and/or is optionally used to stimulate said system at saidwidening.

In an exemplary embodiment of the invention, an intra-ureteralstimulator comprises a tubular element (e.g., a stent-like hollow tube,optionally formed of a mesh) which engages the walls of the ureter. Inanother example, the stimulator includes one or more rings which lodgein the ureter, optionally connected by a wire or cable.

In an exemplary embodiment of the invention, an intra-ureteral deviceoperates by mechanical or thermal stimulation of the ureter, forexample, by an expanding element. Optionally, this expansion simulatesthe effect on the sensory nerves in a manner similar to a ureteralblockage and/or chemical irritation and/or directly stimulates sensorynerve endings.

In an alternative embodiment of the invention a stimulator is mounted ona double pigtail ureteral catheter.

In an alternative embodiment of the invention, the stimulator is mountedon an outside of a ureter. Optionally, such a stimulator is designed tonot interfere with ureteral peristalsis and/or ureteral repositioning,for example, the mounting on the ureter being flexible, optionallyaxially. Such flexibilities are optionally provided for intra-ureteralcatheters as well. Optionally, the stimulator provides stimulationspecifically to the desired location without stimulating other targets,for example by isolation of the stimulator from other organs.

In an alternative embodiment of the invention, a stimulator is insertedtranscutaneously directly into the kidney. Optionally, the stimulator isinserted transcutaneously. In an alternative embodiment of the inventiona stimulator is mounted on a nephrostomy catheter.

Optionally, the stimulator includes a distal expanding portion, forexample, a single wire which folds into a spatial shape, to help anchorin the kidney, bladder, and/or kidney pelvis. Such a design may also beused for a stimulator which lies in the ureter.

In an exemplary embodiment of the invention, a stimulating device canapply multiple therapies, for example, applying, in addition tomodification of kidney or body function or alternatively thereto, one ormore of bladder stimulation to assist, prevent modify and/or otherwisemodulate voiding, nerve stimulation and/or sphincter function and/or isused for treating one or more of stress incontinence, neurogenicbladder, atonic bladder, cystocele and/or urinary tract infection (e.g.,by better drainage of urine). Additionally, for example as describedbelow, stimulation can include multiple stimulations in the urinarysystem, such as ureters and in addition nerve(s) and/or blood vessel(s)and/or stimulation of other body systems, such as the heart orbaro-receptors in the carotid arteries or vagus nerves or nervousplexuses. Optionally, renal stimulation is used to counteract a negativesystemic effect which would affect the kidneys and caused by vagal (orother nerve) stimulation. For example, reduced blood pressure may reducerenal blood flow to a damaging level. Stimulation in accordance withsome embodiments of the invention can increase renal flow while not bestrong enough to negate the systemic treatment. Optionally, renalstimulation is used to modulate such a systemic (e.g., vagal nervestimulation, medication) treatment.

An aspect of some embodiments of the invention relates to treatingmodifying or maintaining body functions using a urinary systemstimulator device (or system). While in some embodiments of theinvention a device may apply an open loop treatment, whereby a therapyis set for a desired effect, in an exemplary embodiment of theinvention, the device includes an input, optionally from internal orexternal sensor (or more than one sensor) which generates an indicationof body function, or input from other devices, such as a pacemaker orurine analysis system and/or input form a user, such as a subjectivefeeling. Optionally or alternatively, the stimulation device is used tocommand and/or control such systems and/or interoperate, for example,preventing interference of function and/or of sensing, allowing afeedback loop to be closed. In an exemplary embodiment of the invention,the sensor includes a sensor of kidney function and urinary parameters,such as one or more of urine chemistry, urine volume and urine flow.Optionally or alternatively, the sensor includes a physiological sensorfor kidney function, for example, GFR, urine flow, urine composition,secretion of hormones from the kidney (in blood and/or urine),creatinine levels, inulin levels. Optionally or alternatively, thesensor includes a sensor of urinary systems function, for example,urinary parameters, peristalsis and/or pressure. Optionally oralternatively, the sensor includes a physiological sensor fornon-urinary systems, for example, blood chemistry, blood pressure, heartrate, breathing rate, lung fluid volume and/or ECG. Optionally oralternatively, the sensor includes an input for user entry of a commandor of a physiological parameter. Optionally or alternatively to aphysiological sensor, an environmental sensor is used, for example, anacceleration sensor may indicate movement (and thus suggest bloodpressure changes) or body posture (e.g., supine, possibly indicating arest period when cardiac demand is lower) and a temperature sensor mayindicate environmental temperature (and thus suggest sweating rate).

In an exemplary embodiment of the invention, the stimulation applied bythe device is set so as not to cause pain or even not to cause aperceptual feeling. Typically subjective feeling of electricalstimulation depends on the waveform, the frequency and the amplitude ofstimulation, as well as on the stimulated area (above and beyond asensed functional effect), for example, due to nearby tissue musclecontractions and/or pain receptors in that tissue. In the bladder, sinewaves are generally less tolerated than square waves, possibly due tothe larger current flowing in the sine waveform. In general, higherfrequencies are less irritating; bladder stimulation is not felt up to 2mA stimulation with a 2000 Hz sine wave, 1 mA with 250 Hz and 0.5 mAwith 5 Hz, suggesting that bladder sensation is mediated by C-fibersthat are sensitive to low frequency stimulation. The urethra is about4-10 times more sensitive to electrical stimulation. The trigone appearsto not generate sensations up to 16 v with 2500 Hz square wavestimulation. In an exemplary embodiment of the invention, stimulation ismaintained below these values. In some cases, even pain or sensationcausing stimulations may be used, depending on the importance ofstimulation. Optionally, larger electrodes are used to reduce thecurrent density and possibly pain which relates to current density.

In an exemplary embodiment of the invention, the stimulation has acontinuing effect even after it is stopped, for example, an effectlasting at least 3 minutes, 20 minutes, 1 hour, 2 hours or intermediatetimes. In an exemplary embodiment of the invention, longer periods areused for having a useful lasting physiological effect. Shorter periodsare optionally used for feedback and/or to determine stimulationparameters. Optionally, the stimulation is not repeated for such timeperiods while the effect lasts.

In some experiments it was observed that the duration of an after effectappeared dependent on the duration of stimulation. In an exemplaryembodiment of the invention, the stimulation sequence used assumes afactor of, for example 1.5, 2, 3, 5, 10 or intermediate or greaterfactors, between stimulation time and expected useful effect duration.Optionally, the link for a particular patient is determined, forexample, during calibration, and used as part of a plan for and/orselection of for stimulation sequences therefore.

In an exemplary embodiment of the invention, the stimulation includespositively affecting or controlling two kidneys, optionally, controllingone kidney in opposite to an effect expected by control of the otherkidney.

In an exemplary embodiment of the invention, the device is used fortreating one or more of acute or chronic high blood pressure, acute orchronic heart failure, myocardial infarct, acute or chronic renalfailure, nephrotic syndrome, hepatorenal syndrome, cardiorenal syndromeand other disease states. Optionally, the sensing is used to indicatewhen a particular therapy is working and can be stopped or slowed downand/or when a specific therapy is not working and should be changed.

In an exemplary embodiment of the invention, the following treatmentprotocols are used for particular disease states. For shock patients(e.g., including septic shock), it is noted that these patients sufferfrom reduced blood pressure and can be treated by vasoconstrictors inorder to increase systemic vascular resistance and increase bloodpressure; but it often results in renal failure, due to reduced renalperfusion. Optionally, increase of the reno-renal reflex is used toprotect the kidneys during the treatment. For detoxication, for exampleof substances that are excreted by the kidneys, increased kidneyperfusion can be used to eliminate the toxins more quickly. For acuterenal failure there are anecdotal reports showing that increasing renalfunction during acute tubular necrosis phase of renal failure canimprove the clinical condition. Optionally, a treatment starts as earlyas possible, lasting up to a few days following the initial damage.Optionally, renal blood flow is increased using a reno-renal reflex orother stimulation, while renal function is reduced, for example, byadrenaline. For chronic renal failure, in general, these patientsbenefit from diuretics, if not for their harming effects on the GFR. Achronic stimulation of the reno-renal reflex (to increase it) withdiuretic administration may be used for such patients.

In an exemplary embodiment of the invention, the device coordinates withanother device that applies a non-urinary system stimulation, forexample, cardiac pacing or a medication pump or a transdermal medicationapplication patch.

In an exemplary embodiment of the invention, the device is programmedwith a plurality of possible stimulation protocols. Optionally, a tableor algorithm is provided which matches stimulation profiles with desiredeffects, physiological conditions and/or possible side effects.Optionally or alternatively, a correction is provided for varioussituations, such as age or diabetes, in which cases the stimulationintensity required for desired effect may be doubled and/or optionallyprogrammed by a user.

An aspect of some embodiments of the invention relates to devices forstimulating tissues near the bladder, for example, the urinary bladdertrigone and/or distal ureter area. In an exemplary embodiment of theinvention, such a device includes a stimulator which resides, at leastin part in the bladder. Optionally such a stimulator is equipped with anexpanding part, optionally a balloon, which dwells in the bladder,optionally an inflating part of a Foley catheter. In an exemplaryembodiment of the invention, the stimulator is shaped so that access tothe trigone and/or the ureter is not blocked by an enlarged prostate.Optionally the balloon is not spherical, for example a torus, for bettercontrol of location of stimulation. Optionally, the stimulator is aballoon with a concavity matching the bulging prostate area. Optionallyor alternatively, the stimulator includes an adapting mechanism matchinga protrusion into or distortion of the bladder caused by organ prolapse.Optionally the adapting mechanism is the ability of the device to changeits form, optionally to bend to match the distortion of the bladder.Optionally, such a stimulator is designed to not mechanically interferewith urine flow, for example, including a channel for urine to theurethra and/or includes a channel for urine flow from the ureters to thebladder. Optionally the stimulator includes at least one, optionallymore draining holes to fully empty the bladder. Optionally, thestimulator does not fill the entire volume of the bladder. Optionally,the stimulator includes only a wire in the urethra, thereby allowing thebladder neck to operate in its valving function. A potential advantageof a trans-pubic approach is that a direct insertion into the ureterand/or contact with a trigone area may be possible, by transfixing thebladder at a correct orientation and reducing the risk of infection.

In an exemplary embodiment of the invention, the stimulator is designedto have a contact adjacent a trigone or distal ureter area. Optionallythe stimulator includes a plurality of contacts, for different areas inthe bladder.

In an exemplary embodiment of the invention, the bladder is stimulatedat multiple locations, for example, at non-trigone areas. It is believedthat such stimulation, if applied over a sufficient surface of thebladder can activate such sensory nerves which can then trigger ormodulate a vesico-vascular effect. Optionally, controlled differentialstimulation of different parts of the bladder is used to provide controlof the at least practically counteracting reflexes of the reno-renalreflex and the vesico-vascular reflex. Optionally, the degree ofvesico-vascular excitation is controlled by one or more of controllingintensity and controlling surface area stimulated (e.g., a 20% areastimulation generates less of an effect than 60% area stimulation).

Optionally, such stimulations are applied in series, alternatively, theyat least partially overlap in time. Optionally, after a reno-renalreflex is activated, a vesico-vascular reflex is applied to reduce thekidney function to a desired amount (or the trigone may be stimulated toincrease the reno-renal reflex intensity). Optionally, such stimulationsare applied as needed to maintain a desired physiological effect withina desired range, for example, resulting in a series of stimulations ofthe trigone and the rest of the bladder, not necessarily alternatestimulations.

Optionally, the stimulation used is to reduce sensitivity, for example,by hyperpolarization of nerves. Optionally, such dampening stimulationis used, for example, when stimulating the entire bladder, to firstdesensitize the trigone, so it does not counteract the effects ofbladder stimulation (the ureter is then optionally stimulated to achievea desired effect on the reno-renal reflex). Optionally or alternatively,the relative contributions of vesico-vascular reflex and reno-renalreflex (or other reflexes) can be controlled by reducing thecontribution of one, in addition to or instead of increasing the other.

Optionally, once stimulation shows a desired effect, or instead of suchstimulation, nerve endings in a portion of the bladder may bepermanently ablated to reduce a reflex, such as the vesico-vascularreflex.

In some exemplary embodiments of the invention the stimulation is usedto increase (or reduce) sensitivity, for example, by modification ofreflex gain. Optionally this is provided by electrically stimulatingother reflexes and/or nerves of the urinary system.

In an exemplary embodiment of the invention, sensitivity of variousreceptors, pathways and/or physiological function is tested, bystimulation and/or optionally damping stimulation, as part of adiagnosis process.

Optionally or alternatively, a protocol may include a test session tosee what a patient responds to and/or what a patient may over respond toand a treatment protocol is optionally decided accordingly.

In some cases, kidney voiding problems and/or an enlarged prostate causeover stimulation of a bladder region, thereby causing over stimulationor habitation of a reflex. Optionally, such a physiological condition istreated as a way of affecting such a reflex and having a desirednon-local effect as described herein. For example, a prostate may beresected or shrunk (e.g., using ablation or medication) and/or a urethramay be opened and/or a bladder be stimulated to assist in voiding and/ora bladder may be resected to reduce a surface area thereof.

In an exemplary embodiment of the invention, the stimulator includes aplurality of contacts, but only on one hemisphere thereof. Optionally,the contacts are fewer than 10. In an exemplary embodiment of theinvention, the contacts, all or some, are positioned to specificallyreach the trigone area. For example, if the stimulator is a balloonentering from the urethra, a distance between the urethra and thetrigone is used to set the distance between the contacts (or some ofthem) an a part of the balloon that contacts the bladder neck.

An aspect of some embodiments of the invention relates to non-electricalstimulation of the urinary system, for example, thermal, mechanicaland/or chemical stimulation of the ureter, trigone and/or kidney. In anexemplary embodiment of the invention, a device for mechanicalstimulation includes an element which expands inside the ureter andthereby simulates a blockage. Optionally, the element does not blockurine flow. Alternatively, it does.

An aspect of some embodiments of the invention relates to an integratedbladder dwelling stimulation system. Optionally, the system is adaptedto be inserted through a urethra. Optionally or alternatively, thesystem is adapted to be inserted via the pubic area. Optionally, thesystem includes, in a single unit, sensing, control and power.Optionally, the system is designed to specifically stimulate thetrigone. Optionally, the system is simple and/or designed for disposing,for example, not including an on/off control and/or including only apower control, so that a setting which is effective but not painful orcausing discomfort, may be selected.

Before explaining at least one embodiment of the invention in detail, itis to be understood that the invention is not necessarily limited in itsapplication to the details of construction and the arrangement of thecomponents and/or methods set forth in the following description and/orillustrated in the drawings and/or the Examples. The invention iscapable of other embodiments or of being practiced or carried out invarious ways.

Exemplary Method and Apparatus

Referring now to the drawings, where FIG. 1 is a flowchart of a method4000 of controlling body physiology using stimulation of the urinarysystem, in accordance with an exemplary embodiment of the invention.FIG. 3 is a simplified schematic block diagram of a urinary systemstimulation system 4100, in accordance with an exemplary embodiment ofthe invention.

In an exemplary embodiment of the invention, stimulation system 4100comprises a stimulator 4110, optionally an electrical stimulator, butpossibly a stimulator of a different type, for example, chemical,thermal or mechanical. Stimulator 4110 is optionally coupled to acontroller 4104 by a lead 4108. Alternatively, a wireless coupling maybe provided. In an exemplary embodiment of the invention, controller4104 includes a power source 4106, such as a battery. Optionally, thebattery has enough power for treating a patient for at least 1-3 years.In some embodiments, a small battery, suitable, for example, for 1-6days or 1-4 weeks, is provided. Optionally, controller 4104 is enclosedin a housing 4102, for example, suitable for implantation in the body orfor survival outside the body. Optionally, an input source 4112 isprovided, for example, for user input or for sensor input and/or for atime signal.

At 4002 a patient is optionally diagnosed. In some cases the diagnosisis pre-existing. In other cases, stimulation of the urinary system willhelp in determining a diagnosis. In an exemplary embodiment of theinvention, stimulation is used as part of a diagnostic method. Forexample, patients having hyperactivity of the renal nerves may beidentified. For example, in CHF patients, there is a variability in thefunction of sympathetic renal nerves. It is expected that stimulation inaccordance with some embodiments of the invention would have a morepronounced effect on high renal nerve activity patients. After suchidentification, such patients may be treated, for example, using achronic device, using a nerve or vessel stimulator such as suggested byU.S. Pat. No. 7,162,303 and US patent publication 2006/0212078 and/or amore vigorous anti-sympathetic therapy.

Optionally or alternatively, various kidney functions may be measured.Optionally, weariness of the kidneys can be identified by determininghow well the kidneys respond to stimulation. Optionally oralternatively, diagnosis comprises bypassing various parts of the renalsystem to see where a normal response is detected. For example, ifstimulation of afferent nerves has an effect that ureter stimulationdoes not, this suggests a damaging of the ureteral nerve endings.

In an exemplary embodiment of the invention, a degree of renalsympathetic drive can be measured from the timescale/amplitude of theresponse to reno-renal stimulation. As taught by Schramm et al,activation of the reno-renal reflex reduces the attenuation of renalfunction during sympathetic stimulation. The reno-renal reflex can alsoslow the renal response to renal nerve stimulation. Optionally, a numberof different intensities of stimulations are provided and the patient'sresponse (for example blood pressure and/or urine flow) is measured.Comparison of the effects of stimulation can provide the gain of thesympathetic system and the responsiveness of the kidneys and/or thecardio vascular system.

At 4004 a treatment is optionally selected. As noted, in some cases,stimulation of the urinary system is used to help in choosing atreatment protocol, for example to see which stimulation has atherapeutic effect with acceptable side effects. In an exemplaryembodiment of the invention, the treatment is selected to affect one ormore of kidney function, blood chemistry and/or cardiovascularparameters, such as blood pressure and susceptibility to arrhythmia(e.g., by lowing sympathetic activity).

At 4006, stimulator 4110 is provided, if one was not provided before. Asdescribed herein, stimulator 4110 may be, for example, external,transcutaneously implanted, trans-urethrally implanted and/or insertedin the vagina or rectum of a patient. FIG. 2 below shows exemplarytarget stimulation locations, in accordance with some embodiments of theinvention. In an exemplary embodiment of the invention, stimulator 4110is provided on a urinary catheter which is also used to measure urinaryoutput and/or ensure bladder evacuation.

At 4008 the urinary system is stimulated using stimulator 4110. In anexemplary embodiment of the invention, stimulation system 4100 isprogrammable with a set of parameters which may be selected, forexample, based on a desired treatment.

At 4010, an additional treatment is optionally provided, for exampledrugs (to affect the body and/or urinary system in particular) orelectrical stimulation, for example, of the urinary system, nervoussystem and/or the heart. Optionally or alternatively, an existingtreatment, such as diuretic medication may be modified to take intoaccount the stimulation of the urinary system. Optionally oralternatively, a synergistic result is to be obtained between acts 4008and 4010.

At 4012 feedback is optionally provided, for example, by providing aphysiological indication, such as blood pressure, urine volume, GFR,blood flow, impedance, weight, blood chemistry.

At 4014, one or more stimulation parameters and/or treatment parameters(of 4010) are optionally changed taking the desired result and/orphysiological indication(s) into account. This may result in repeating,for example, diagnosis, treatment selection and/or urinary systemstimulation and/or other treatment.

At 4016, additional input is optionally provided, for example, usercommands (e.g., reduce blood pressure, increase blood pressure,medication taken), programming and/or non-physiological sensor input(e.g., accelerometers indicating alertness or posture,laboratory/external urine analysis results), and optionally used indetermining stimulation and/or treatment parameters. Optionally oralternatively, this input is used to determine which stimulator to useand/or what physiological measures to check.

At 4018 a stimulator is optionally removed (e.g., when not needed) orchanged (e.g., by replacing an external stimulator having atrans-urethral stimulation with an implanted stimulator. For example,such replacement may be useful when a temporary stimulator is used todetermine parameters and/or suitability of a permanent stimulator.

While various possibilities of treatment and stimulator configurationare described below, a particular exemplary stimulation system includesa trans-urethral catheter terminating in a balloon configured toelectrically stimulate trigone tissue in the bladder. In an exemplaryembodiment of the invention, the stimulation is used to increase kidneyfunction including, for example, one or more of renal blood flow,filtration rate, urine production, salt excretion and/or reduction ofblood pressure possibly by activating a reno-renal reflex. Optionally,such increase in kidney function is used to alleviate heart failureand/or hypertension.

It should be noted that in some embodiments of the invention, only alead is implanted, and in some cases the implantation is temporary,being, for example, by placing in a urethra. In other embodimentsimplantation is longer term, includes forming new apertures in the bodysurface and/or organs and/or includes a more robust attachment to tissuethan a structure which urges a stimulator against a tissue. For examplea stimulator may be implanted for, for example, 3 days to 2 weeks, 1-6months, 1-5 years, or shorter, intermediate or longer periods.

The above has described an exemplary system and method for stimulating aurinary system, in accordance with some embodiments of the invention.Following are examples of therapies and/or effects which may be achievedby such a system, thereafter are described several alternativesubcomponents of such a system, for example, stimulator type, stimulatorlocation and designs for different implantation methods. It is to bestressed that a practical implementation of some embodiments of theinvention may include picking and choosing particular therapies,programming, structural features, options and/or implantation methodsand/or adaptations from several and/or different ones of the sectionsbelow.

Exemplary Target Locations

FIG. 2 is a schematic diagram of a urinary system 4200 showing exemplarytarget stimulation locations, in accordance with an exemplary embodimentof the invention. It should be noted that different types of targetsaffect different body functions and/or have a different difficulty levelin access thereto and/or stimulation thereof. There is also a differencebetween the targets with respect to the order of their effect on kidneyand/or body functions. For example, some targets cause the secretion ofhormones, some targets are active organs (like nephrons), some targetsare general nerves of the body or blood vessels that lead blood to thekidneys and some, in an exemplary embodiment of the invention, aretargets that modulate or trigger existing reflexes, thereby indirectlyaffecting various body and/or kidney functions.

In general, the urinary system includes two kidneys 180, connected bytwo ureters 182 at kidney pelvises 181, the ureters further beingconnected to a bladder 183 by uretero-vesical junctions (UVJ) 193, whichtogether with a urethral orifice 184 form a trigone area 4210. All ofthese body parts are adapted to hold urine, and some, such as the ureterand bladder are muscular. In some cases, the stimulation increases theforce of contraction of the ureter.

In the following various potential targets are listed. Some of thesetargets may have been used in the art but in conjunction with othertargets, other methods of control, devices and/or methods describedherein, are novel. In an exemplary embodiment of the invention, targetsinclude targets that are within a control loop of the kidney, forexample, nerves and/or tissue which modulate and/or trigger existingreflexes, such as the reno-renal reflex and the vesico-vascular reflex.In an exemplary embodiment of the invention, targets are within theurine flow system, which allows ease of access for temporaryimplantation and/or acute treatment.

For example, one or more of the following targets may be used:

(a) the inside surface 4202 of urethra 184, e.g., using anintra-urethral electrode; this may be an easy to stimulate locationwhich is close to trigone 4210 (e.g., if parts near UVJ 193 arestimulated), stimulation can contract the urethral sphincter and/oractivate the reno-renal reflex;

(b) the outside surface 4204 of bladder 183; e.g., using implantablestimulator; Depending on the location of stimulation, different reflexescan be activated; for example the stimulation can activate thevesico-vascular reflex, but if located at posterior locations, near theureters, can also activate the reno-renal reflex;

(c) intramuscular portions 4206 of bladder 183; e.g., using a catheterbased device, an implantable lead and/or a suprapubic device; such alead or device may include a tissue penetrating electrode such as prongsor a screw (e.g., with a contact at the prong or screw), which can beused also in a trigone area;

(d) portions of the inner bladder wall 4208; e.g., using catheter orsuprapubically inserted device; optionally this uses an easy to insertdevice; optionally the stimulation can activate the vesico-vascularreflex;

(e) the trigone area of the bladder 4210; e.g., using a catheter, asuprapubically inserted device or an implantable device; specificactivation of the trigone activates the reno-renal reflex (or dampensit, if inhibitory stimulation is used);

(f) distal portions 4212 of the ureter near or at the connection to thebladder; e.g., with a ureter catheter based device; Optionally theureter region is used for specific reno-renal reflexactivation/modulation;

(g) distal portions 4214 of the ureter, somewhat distanced from thebladder, e.g., within 2-3 or 3-5 or 5-10 centimeters from the end,optionally near a junction of nerves and the ureter;

(h) mid-ureteral regions 4218, for example, using a stimulator mountedon the ureter 182;

(i) inside surfaces 4216 (or within wall portions) of the ureter at anypoint thereof, for example, using an intra-ureteral catheter or anextra-ureter stimulator, either optionally connected to a implanteddevice;

(j) proximal portions 4220 of the ureter; e.g., with a ureter catheteror a nephrostomy device;

(k) pelvic portions 4226 of the kidney, optionally inner surfacesthereof; stimulation can optionally control ureteral peristalsis inaddition to activation of the reno-renal reflex.

(l) the cortex 4222 of the kidney, for example, its outside surface(e.g., the renal capsule), optionally under a fat layer thereof;

(m) internal structures 4224 of the kidney, for example, one or more ofa Renal pyramid, a Renal hilum, a Minor calyx, a Major calyx, a Renalpapilla and/or a Renal column; and/or an active kidney portion such as aNephron;

(n) lumens 4228 in the kidney.

Optionally or alternatively, nerves that innervate or otherwise affectthe kidney are stimulated to affect kidney or other body function.Optionally, the nerves may be one or more of afferent nerves, somaticnerves, parasympathetic nerves and sympathetic nerves. Optionally anerve ganglion or other plexus (e.g., the spine) is stimulated, todirectly or indirectly affect such nerves. A particular advantage ofstimulating afferent nerves is that such stimulations allows existingkidney feedback mechanism to be manipulated as if a real event washappening. In an exemplary embodiment of the invention, the nervestimulated is a nerve that is directly connected to a kidney. In otherembodiments, the nerve is not directly connected to a kidney, forexample, a nerve connected to a spine. In one example, a vagal nerve isused to affect general body nervous tone and an additional stimulationused to specifically affect a kidney.

In an exemplary embodiment of the invention, the nerves being stimulatedenervate the urinary system and/or are adjacent thereto (e.g., arestimulated within 2-5 cm, optionally 1-3 cm, optionally about 1 cm, fromtheir connection to the urinary system). Possibly this will increase thelocality of the stimulation and reduce undesired effects on other bodysystems

In an exemplary embodiment of the invention, the targets include one ormore of a Splanchnic nerve 188, a Pelvic nerve 186, a Pudendal nerve185, a Pelvic ganglion 187, a Celiac ganglion 189, a spinal cord portion191 or 192 and/or a Vagus nerve 190. It should be noted that, ingeneral, nerves may be less desirable to stimulate if their stimulationis not specific and/or if there is a danger of inflammation of thenerve.

Optionally or alternatively, blood vessels (not shown) are stimulated,for example, one or more of an Interlobar artery a Renal artery, a Renalvein and an Interlobar vein. Stimulating vessels can be used to increaseor reduce blood flow to the kidneys.

A particular advantage of stimulating urine holding tissues is that suchtissues may be more robust and/or more muscular and easier to contactwithout damaging. Another potential advantage of stimulating functionaltissue, rather than nerves, is that such stimulation may assist insimulating a desired behavior of the kidneys using pre-existing feedbackmechanism. For example, stimulating a ureter can be used to simulate anobstruction in the ureter and/or the sensory signals caused by suchobstruction, thereby triggering biologically natural reflexes andfeedback loops. In another example, stimulation of sufficient parts ofthe bladder can simulate a full bladder, and thereby reduce kidneyfunction. In some examples, stimulation is targeted at locations in thebody which include receptors, such as force receptors and chemoreceptors.

Exemplary Stimulation Effects

FIG. 5 is a block diagram showing exemplary effects of stimulationaccording to some embodiments of the present invention, on body systems,not intending to be a complete such exposition.

Bold boxes include external stimulations, some generally known (e.g.,diuretics 6000) and some novel (e.g., stimulation of the ureter 6002).Unbolded boxes indicate effects of such stimulations. An importantfeature shown in this figure is the multiple inputs for some of theeffects. In an exemplary embodiment of the invention, to achieve adesired effect, multiple inputs may be provided, inputs which worktogether and/or inputs which interfere. Additionally, some inputs may bereduced (e.g., medication 6002, 6004, 6006, 6008, 6028) if theyinterfere with a desired effect. Optionally or alternatively, differentinputs are provided at different times of day, for example, when theirside effects are less bothersome and/or to provide different modes ofinterference with body function at different time, which may preventhabitation and/or adaptation.

As shown activation of the vesico-vascular reflex 6010 can increaserenal sympathetic activity 6020, which can then lead to one or more ofdecreasing renal blood flow 6012, decreasing GFR 6014, decreasingdiuresis 6016, decreasing natriuresis 6018 and/or increased reninsecretion 6022. These last two can cause increased blood pressure 6024,optionally in cooperating with increased renal sympathetic drive 6020.Blood pressure can also be increased using blood pressure elevatingmedications 6008 and by systemic increased sympathetic activity 6026.Diuretics 6000 can also increase renal sympathetic drive 6020 andtherefore increase blood pressure 6024.

Blood pressure lowing agents 6006 can decrease blood pressure, as canACEI and ARBs (angiotensin blockers) 6028 which reducerenin-angiotensin-aldosterone axis activation. Alpha and beta blockers6004 can reduce the systemic sympathetic activity 6046 and therebyreduce blood pressure 6030.

Diuretics 6000 can also increase diuresis 6032 and/or natriuresis 6034(which can reduce blood pressure 6030).

Stimulation of the ureter and/or trigone areas 6002 can evoke thereno-renal reflex and/or, for example, reduce renal sympathetic drive6036 and/or increase renal and/or systemic CGRP (calcitonin gene-relatedpeptide) secretion 6038, which can then increase renal blood flow 6040,increase GFR 6042, increase diuresis 6032, increase natriuresis 6034and/or reduce renin secretion 6044.

In general, treatment of any particular patient may be a navigation of amaze of interactions and counter-interactions between stimulations andtreatment, while taking into account the responsiveness of a patient andhis/her danger zones. Optionally, a stimulation system and/or amonitoring system are programmed with such interaction (e.g., 3, 4, 5 ormore interactions) and used to predict and monitor the effect oftreatments and/or suggest treatments and/or treatment levels.

In accordance with exemplary embodiments of the invention, one or moreof the following effects on urinary system function is achieved:

(a) increasing a kidney activity and/or a function, for example, byaffecting a urinary system reflex;

(b) reducing a kidney activity and/or a function, for example, byaffecting a urinary system reflex;

(c) increasing or decreasing peristalsis in a ureter, for example, byoverpacing a ureter or by applying a desensitizing stimulation to theureter (e.g., a hyper-polarizing stimulation, such as DC or a highfrequency stimulation); Optionally, over pacing is to above a normalrate, for example, to above 3, 4, 5 or more peristaltic waves perminute.

(d) increasing or decreasing renal blood flow, for example, bystimulating renal vessels and/or modulating a reflex; increasing renalblood flow may increase kidney function and vice versa;

(e) modulate a reflex, for example, by stimulating or dampening sensorynerves associated therewith;

(f) trigger a reflex, for example, by stimulating an input thereto;

(g) stimulate receptors to modify a baseline activity thereof (e.g.,increase or decrease), thereby making a reflex weaker or stronger for asame stimulation or physiological condition;

(h) release hormones, for example, to cause local and/or body widevasodilatation or vasoconstriction;

(i) modify nervous activity, for example, by stimulating a nerve; and/or

(j) modify cardiovascular function, such as blood pressure, heart rate,vessel dilation and/or resistance and/or susceptibility to arrhythmia,for example, by releasing hormones, preventing the release of hormones,modify an intensity of a reflex and/or modifying systemic sympatheticactivity.

Additional exemplary details follow.

Dampening or exciting receptors. Pressure and chemo-receptors in theurinary system can be activated by electrical stimulation. Some of thesereceptors are NMDA glutamate receptors, which are known to have aprolonged timescales of activation and can be pushed to longdesensitization states by high frequency stimulation. In addition,activation of NMDA receptors is very frequency dependent, frequencies aslow as 5 Hz stimulations can progressively increase receptor activation,for example see Polsky et al. Different patterns of electricalstimulation can selectively excite or dampen receptor activity. NMDAreceptors are also the main mediators of long-term potentiation anddepression, which are important mechanisms of modulation of neuralactivity and neural reflexes. As known in the art, to excite a nerve,electrical stimulations are usually given in short pulses of up to 10 msin length or by sinus wave shaped currents. To dampen nerve function,long DC currents or very high (e.g., >1000 Hz) stimulation frequenciescan be applied.

Activation and modulation of the reno-renal and the vesico-vascularreflexes. A team lead by DiBona and Kopp revealed in a number of seminalpapers that the reno-renal reflex is normally activated by a rise inpressure or sodium concentration in the collecting system, the renalpelvis and the ureters (any of which are stimulated in accordance withan exemplary embodiment of the invention). The reflex can be naturallyactivated by sensing from one side of the urinary system, but the normaleffect is a bilateral reduction of the sympathetic input and increase inCGRP-mediated effect to both kidneys, as found by Zhu et al.Physiologically, the reno-renal reflex increases renal blood flow, renalfiltration (GFR), diuresis, natriuresis and reduces blood pressure bothby promoting sodium excretion and by a direct effect on brainstemsympathetic ganglions.

The vesico-vascular reflex has a rather opposite effect on thesympathetic system and on some kidney function. It is activated byincreased bladder pressure or bladder distension, as occurs duringbladder outlet obstruction. Chien et al found that activation of thereflex reduces renal blood flow, GFR, sodium and water excretion andincreases renin secretion by renal nerve mediated effect. Fagius andKarhuvaara reported that in human subjects the reflex also increasesblood pressure in a direct proportion to the intrabladder pressures. Theincrease in blood pressure is independent of renal nerves activity orrenal function.

Modulation of reflexes has been shown, for example, in work done byJiang and Lindstrom in the urinary system, who demonstrated a change inresponsiveness of the micturition reflex. Short (5 min) electricalstimulation of the bladder and other pelvic structures effectivelyincreased the threshold for the reflex for at least one hour poststimulation. Possibly, the effect was mediated by change in thestrengths of the synaptic connections in the reflex pathway.

In an exemplary embodiment of the invention, it is noted that the tworeflexes are generally, at least in part, opposite. Optionally, thebalance between the reflexes is changed, for example, by strengtheningone reflex (or exciting or increasing a baseline excitement level ofreceptors associated therewith) and/or by weakening the other reflex(e.g., or dampening a baseline excitation level and/or sensitivity ofits receptors).

Hormone release. The reno-renal reflex is mediated by two nervoussystems—first, it triggers a reduction of the sympathetic activity ofthe kidneys. In addition, it induces release of CGRP in the kidneys.CGRP is one of the most potent vasodilators in the cardiovascular systemand it is known to cause both arterial and venous vasodilatation. Inaddition, it can elevate renal functions; for example, in a work done byLi and Wang and it was shown to increase GFR, urine flow and natriuresisin rats. CGRP infusion to human CHF and CKD patients was shown todecrease blood pressure and increase renal blood flow and GFR (Shekharet al and Palla et al). These studies had also shown that CGRP has arelatively long effect lasting a few hours, despite a relatively shortplasma half live of about 10 min.

CGRP is probably released from simulated afferent nerves in accordancewith some embodiments of the invention, as these nerves have bothsensory and excretory functions.

Zhu et al had shown that activation of the reno-renal reflex byincreasing ureteral pressure increased plasma CGRP levels. However, themean CGRP concentration achieved by this stimulation was about 10 foldlower than the minimally effective infused CGRP levels. By sufficientstimulation, it is believed that these levels will be reached, forexample, 7, 10, 15, 20 or more of normal levels. Optionally, suchresults are achieved by applying a train (e.g., 10 or 20 or intermediateor larger number) of stimulations with rest periods (e.g., 10-40 secondsor 1-15 minutes) between, so that the nerves are re-stimulated by eachstimulation to excrete more CGRP.

In some embodiments of the invention, CGRP levels are measured in theurine and/or the blood. Optionally or alternatively, stimulation isrepeated enough so that significant (e.g., vessel dilatation affecting)systemic levels of CGRP are provided, optionally measured by blood testand/or measuring vessel diameter (e.g., with a vessel cuff or anultrasound transducer measuring a signal across a vessel).

Regarding the role of CGRP in ureteral innervation. Lang et al describedthe inhibitory effect of CGRP on the motility of the isolated renalpelvis and ureter. The effect of CGRP is especially evident in theureter as a suppression of evoked motility: the all-or-none suppressanteffect probably occurs because CGRP abolishes the firing of actionpotentials evoked either by electrical stimulation or chemical agents. Adescending gradient exists in the guinea pig pyeloureteral tractregarding sensitivity to the inhibitory effect of CGRP: the ureter isextremely sensitive, whereas the spontaneous activity of the renalpelvis is inhibited but not suppressed by this peptide. CGRP is the mainmediator involved in the local regulation of ureteral motility: its maineffect can be described as a powerful suppression of latent pacemakersof the ureter smooth muscle. Optionally, motility is controlled, forexample by pacing, to overcome a motility reducing effect.

It should be noted that while some of the above effects have beendescribed in the art, they have not generally been described as beingpart of a system for control of bodily functions. Rather, someembodiments of the invention utilize what is known with respect tobiological interactions and provide a control system based thereon.

Exemplary Relationship Between Stimulation Location and StimulationEffect

Following are examples of relationships between stimulation location andeffect on kidney function, in accordance with exemplary embodiments ofthe invention:

(a) stimulation of the trigone area or ureters can be used to evoke thereno-renal reflex; and

(b) stimulation of the bladder can be used to simulate a full bladderand evoke a vesico-vascular reflex, or to prevent such a reflex frombeing evoked.

Possibly the renal pelvis is more responsive to stimulation than theureter, and this is used for selecting some embodiments of theinvention.

In some embodiments, stimulation at or near the trigone and/or of asacral is used to affect a closing of a bladder sphincter. A combinedsphincter-closing effect may be useful if there is inadvertent causingof bladder contractions and/or feelings of discomfort.

It should be noted that while some of the stimulations have abiomechanical effect (e.g., peristalsis, sphincter closing),non-mechanical physiological effects, such as on blood pressure andkidney function, are often more of interest.

Exemplary Multiple Stimulation

In an exemplary embodiment of the invention, a stimulation system isused to stimulate a plurality of targets in the body and/or urinarysystem. Optionally, a plurality of such targets are stimulated in a sametherapeutic session. Optionally or alternatively, such targets may bestimulated substantially simultaneously, for example, within 1 minute, 5minutes, 20 minutes, 35 minutes of each other, or intermediate or longerperiods.

In an exemplary embodiment of the invention, sequential stimulation ofdifferent targets is used to modulate an effect. For example, a firststimulation target triggers a reno-renal reflex. A second stimulation isthen applied after a time to, for example, evoke the vesico-vascularreflex an thereby reduce the effect of the previously evoked reno-renalreflex to a desired amount. A urinary system specific stimulation isused together with a systemic stimulation, for example, a reno-renalreflex applied at a same time as a vagal stimulation. In anotherexample, a combination of a medication and a stimulation is used, forexample, evoking the reno-renal reflex to counteract a reduction inrenal functions or enhance the effect of a diuretic.

Optionally, different kidneys are differently controlled, for example,by supplementing the reno-renal reflex using another stimulation method.One of the stimulations may be a baseline stimulation for one or bothkidneys and the other used for modulation of both kidneys or only one.

In accordance with some exemplary embodiments of the invention, what isprovided is a controller for urinary and/or other body functions. In anexemplary embodiment of the invention, the controller is used todirectly or indirectly affect the underlying patho-physiological causesof some important diseases. Optionally, such a controller can replace,enhance/decrease and/or support existing body feedback cycles, receptorsand/or sensor function. In an exemplary embodiment of the invention,such a controller substitutes normal or corrected responses for sensedbody conditions, in a manner which compensates for damaged receptorpathways and/or prevents a self-reinforcing syndrome, such as acardio-renal syndrome. Optionally or alternatively, such a controllercan provide long term therapy and/or short term therapy, as desired.Optionally, such a controller can be used to specifically modulate afunction of one organ, optionally the kidneys, for example providingopposite effects (e.g., otherwise physiologically incompatible) ondifferent organs.

Exemplary Treatment Combinations

Several exemplary treatment combinations follow. These are onlyexemplary combinations and many of the stimulations described herein canbe combined with stimulations of types known in the art to provide amyriad of different treatment options, optionally with a synergistic,compensating and/or side-effect-reducing effect.

(a) Reno-renal reflex activation+systemic vasoconstrictors that mayinclude sympathetic activation (alpha and/or beta agonists); vasopressinagonists; somatostatin agonists—this combination can elevate bloodpressure and ensure perfusion to the heart and brain withoutcompromising renal blood flow.

(b) Reno-renal reflex activation+diuretics—boost the effectiveness ofdiuretics by enhanced renal delivery due to increased renal blood flow.

(c) Reno-renal reflex activation+sympathetic inhibition (e.g.,beta-blockers)/ACEFARBs—increase the blockage of the renal sympatheticactivity and its negative effects on cardiorenal interactions.

(d) Reno-renal reflex activation+water and/or saline infusion thatincreases plasma volume, for example to increase blood pressure andrenal function and aid in salt removal.

(e) Reno-renal reflex activation+splanchnic vasoconstrictors (e.g.,vasopressin V1), to redistribute blood flow from the splanchniccirculation to the kidneys.

(f) Reno-renal reflex activation+Vesico-vascular reflex activationsimultaneously or not, to control renal and cardiovascular function asdesired.

(g) Vesico-vascular reflex activation to increase blood pressure.

(h) Inhibition of the vesico-vascular reflex to reduce blood pressure.Reduction of the reflex can be performed with a pharmacological agentsuch as capsaicin (e.g., infused into bladder, optionally whileprotecting trigone area) or by electrical stimulation, for example by ahigh frequency electrical stimulation or DC stimulation.

Exemplary Systemic Effects

In an exemplary embodiment of the invention, the above effects on kidneyfunction and/or direct effects of urinary system stimulation on bodyfunctions are used to provide one or more of the following systemiceffects:

(a) Blood pressure reduction. This may be achieved, for example, byincreasing renal urine and sodium output, for example by increasingkidney function in one or both kidneys. This also can be achieved bydecreasing sympathetic activity, for example by activation of thereno-renal reflex or decreasing of the vesico-vascular reflex.

(b) Blood pressure increase, for example by activation of thevesico-vascular reflex or inhibition of the reno-renal reflex.

(c) Diversion of blood to other organs, while optionally maintaining atleast a minimum renal blood flow. This can be done by a number ofmethods, according to a desired effect. For example, systemic orspecific (for example splanchnic) vasoconstrictor agents can be given,together with activation of the reno-renal reflex. In this way bloodflow will be redirected from the systemic or splanchnic circulation tothe vital organs (heart, brain) and to the kidneys. Vesico-vascularreflex can decrease renal blood flow and increase peripheral vascularresistance.

(d) Change in cardiac load. Cardiac afterload is reduced by reduction ofblood pressure, as provided for example by examples described herein.Activation of the reno-renal reflex reduces the total body sympatheticactivity and therefore will reduce the sympathetic chronotropic andinotropic effects on the heart.

(e) Temporal redistribution of kidney function and/or load on bodysystems, temporal modulation of kidney function, for example, to whenblood flow is needed in other body parts (e.g., when walking) or not(e.g., when sleeping). This may compensate for damaged blood flowphysiological regulation mechanisms.

(f) Kidney rest. Selective control of kidney function by a combinationof reno-renal and vesico-vascular reflexes in combination with systemictreatments can halt and restart the activity of the kidney as needed.

(g) Change plasma sodium concentration. Activation of the reno-renalreflex alone or in combination with infusion of sodium will lead to achange in plasma sodium concentration, depending on the intensity ofreno-renal activation and sodium load.

(h) Control of total-body water amount can be achieved by increasing anddecreasing water balance by the vesico-vascular and reno-renal reflexesrespectively.

(i) Increase of renal function, for example by activation of thereno-renal reflex or inhibition of the vesico-vascular reflex.

(j) Various disease states which may benefit by increasing or reducingsystemic sympathetic activity. Many disease states can be affected bysuch modifying, for example, irritable bowel syndrome. In an exemplaryembodiment of the invention, modifying sympathetic activity usingmethods as described herein are used as treatment in diseases where suchmodification may be useful and/or to counteract an undesiredmodification caused by another therapy.

It should be noted that some of the above effects are short term effectsand some are longer term effects. Optionally, when a longer term effectis desired, the stimulation leading to a short term effect is repeated.Optionally, during a calibration state, a patient is tested to determinehis response to stimulations and the duration of effect to be expected.Optionally, the system automatically applies a stimulation and logs itseffect. Optionally, the system tries out a plurality of stimulationswith different parameters and finally selects one according to itsbeneficial effect. Optionally, a user is called to select betweenoptions and/or reprogram the device based on logged effect. In anexemplary embodiment of the invention, a user has a programmer that canbe used to communicate with the device, downloading logs and/oruploading programs and/or tables indicating what stimulation to applyunder what condition (e.g., of sensed signals or input).

Exemplary Treatment of Clinical Conditions

In an exemplary embodiment of the invention, the above kidney effectsand system effects, optionally together with other bodily controlmethods are used for treatment of clinical conditions.

In many conditions, including some cases of CHF, the treatment isoptionally formulated to correct a hemodynamic imbalance. As such, acontrol of blood flow in different vascular beds is often desirable. Inan exemplary embodiment of the invention, fine tuning of the renal bloodflow is provided: renal blood flow should be high enough to maintainadequate renal function. However, in conditions of reduced cardiacoutput, care should generally be taken to insure an adequate perfusionof other tissue when renal circulation is increased.

For CHF patients, exemplary treatment protocol may include measurementsof one or more of patient weight, blood pressure, amount of diuresis,natriuresis, GFR and subjective and objective analysis of dyspnea.Optionally, one or more of cardiac output, renal sympathetic activity(catecholamine spillover), renal blood flow and/or wedge pressure aremeasured as well.

In the case of finding signs of shock and hypoperfusion, the immediatetreatment can be a combination of bladder stimulation to activate thevesico-vascular reflex or administration vasoconstrictors and/oractivation of the reno-renal reflex, for example to obtain a positiveeffect on both blood pressure and renal function, or activation of bothvesico-vascular reflex and reno-renal reflex.

In this case, blood pressure and kidney function monitoring may beespecially important to assess the progression of the treatment, asexcessive vesico-vascular reflex activation may result in hypertensionor acute renal failure. One proposed limit of vesico-vascular activationcan be stimulation till the mean blood pressure reaches a target value(for example 80 mmHg) or GFR deteriorates by a fixed amount (forexample, 20% from control values).

In CHF patients suffering from increased blood pressure, dyspnea,hypernatremia or reduced renal function, activation of the reno-renalreflex with or without concomitant diuretic administration can decreaseblood pressure, reduce weight, effectively remove water and sodium,increase the effectiveness of diuretics, increase renal function,decrease cardio-renal interactions and attenuate dyspnea. In thesepatients, the treatment may continue till the patient reaches a targetweight. Optionally, more complex treatment protocols may be used. Forexample, treatment with stimulation of the reno-renal reflex iscommenced till a fixed amount of diuresis is reached (for example, 1cc/kg/min), the stimulation is then stopped until diuresis drops belowpredetermined value (for example 0.5 cc/kg/min) or GFR decreases (forexample, by more than 20%). Alternatively stimulation can be stopped ifa negative effect occurs, for example, if the mean blood pressure dropsbelow 80 mmHg or if severe hyponatremia is found (for example on a bloodanalysis). The stimulation may be given in a short session, for exampleduring a hospitalization for acute heart failure. In this clinical setupthe effects of reno-renal stimulation may be double; first, the shortterm effect of diuresis to reduce body water levels and reduce dyspneaand ascites/edema symptoms, and/or second, a long term (e.g., one ormore weeks or months or years) protective effect on GFR (e.g., no orreduced GFR reduction, or GFR increase). Diuretic treatment alone isknown to reduce GFR both acutely but more importantly chronically. Renalfunction, mainly GFR, is one of the most important prognostic factors inpatient morbidity and mortality in CHF. Maintaining GFR duringhospitalization is one of the primary goals of CHF treatment. Reno-renalreflex activation increases renal filtration and therefore can protectthe kidneys during hospitalization, and reduce the rehospitalizationrates due to lesser cardio-renal syndrome intensity.

Stimulation of the reno-renal reflex may be used to specifically inhibitthe lethal cardio-renal syndrome present in CHF patients. No currenttreatment modality usefully reduces the sympathetic drive to thekidneys, which is one of the most important mediators of thecardio-renal syndrome. The cardio-renal syndrome, which can be acute orchronic, reduces renal function, increases water and sodium retentionand leads to hypertension, and progressive heart and kidneysdeterioration. Breaking of this pathological process may have a numberof beneficiary effects in CHF patients. First, reno-renal stimulationfrees the kidneys to exert their normal function and correctly controlthe homeostasis of the body. Second, the stimulation may lead to asynergistic effect with other current treatments of CHF, as increasedrenal blood flow will increase renal drug delivery and renal metabolismof drugs, so that they or their metabolites will not reach toxic plasmalevels. Optionally or alternatively, load on the heart may be reduced.

Chronic modulation of kidney function, for example by activation of thereno-renal reflex, or inhibition of the vesico-vascular reflex may havea paramount importance in treating CHF patients and reducing the chroniccardio-renal syndrome. Optionally, the treatment may be in a form ofmultiple preventive acute sessions, for example with a catheter baseddevice. Alternatively, the treatment may include implantation of animplantable device and continues stimulation. The added value of suchstimulation is patient comfort and prevention of heart and kidneyfunction deterioration, lesser hospitalizations and a better quality oflife.

In an exemplary embodiment of the invention, for treatment of CHF and/orhypertension, it is assumed that receptors and/or nerve pathways for thereno-renal reflex are damaged. Optionally, such damage is at leastpartly overcome by over stimulation and/or by stimulating nerves insteadof allowing the receptors to act naturally. Optionally, stimulation isat the location of damaged receptors and either prompts such receptorsinto action or directly stimulates nerve endings, or other partsthereof, at the location, bypassing the damaged receptors.

Some CHF patients suffer from hyponatremia, which can complicatediuretic treatment. In these patients it is possible to selectivelyactivate the reno-renal reflex to increase GFR and diuresis but notnatriuresis. The reno-renal reflex can be combined with sodium infusionand diuretics to elevate plasma sodium levels and increase theeffectiveness of diuretics. In these patients, the decision upontreatments can involve body weight measurements (treatment stopped whena target body weight is reached) and/or serum/urine electrolytemeasurements. For example, stimulation of the reno-renal reflex can bestopped if high urine sodium excretion is found on urine analysis orplasma sodium levels are reduced above some preset value. Optionally,renal sympathetic stimulation at a desired level is provided tocounteract some effects of the reno-renal reflex activation.

When the patient is found to have high renal sympathetic activity, forexample by analysis of renal vein catecholamine amount or renal nerveactivity (e.g., optionally implanted nerve activity sensors), a chronicreno-renal stimulation may be appropriate; with continuation of mayoptionally depending on renal sympathetic activity measurements.

For hypertensive patients the workup may optionally include one or moreof cardiovascular parameters such as blood pressure, and renal functionanalysis (GFR and possibly proteinurea). Renal sympathetic activity maybe measured as well and treated if abnormal.

In hypertension patients, the reno-renal reflex may not functionproperly, possibly due to a dysfunction of sensory receptors. Theproposed treatment can include direct reno-renal reflex activation byelectrical stimulation alone or in combination with known hypertensiontreatment modalities (for example, diuretics, alpha and beta-blockers,ACEI and ARBs, calcium channel inhibitors, etc.). Activation of thereno-renal reflex reduces blood pressure on the short timescale byreducing total body sympathetic system activity and on prolonged basisbecause of a more efficient water and sodium removal. Other treatmentoptions may include a combination of the reno-renal reflex withadditional stimulation targets (for example carotid sinus stimulation)or renal nerve ablation. Length and intensity of reno-renal stimulationmay depend upon blood pressure measurements, so that it can be stoppedor weakened when a target blood pressure is reached. Treatments may beprovided intermittently, when high blood pressure is detected orsuspected by a patient, or continuously, for example with an implantablestimulator, for maintenance purposes.

For patients suffering from CKD, renal function parameters in additionto blood pressure are optionally measured. Renal sympathetic activitycan be determined as well. For example, one or more of the following maybe measured: renal sympathetic activity, GFR, diuresis, natriuresis,body weight, and hemoglobin.

The treatment may depend on the pathophysiology of renal dysfunction.For example, for patients suffering from malignant blood pressure andincreased renal sympathetic activity, activation of the reno-renalreflex can be combined with aggressive antihypertensive treatment, suchas treatment known in the art. For patients suffering from reduced GFRand reduced water and solute excretion, the reno-renal reflex may bestimulated together with diuretic treatment, to assist in water andsodium removal without the risk of renal diuretic-mediated shutdown. Inthis case, the stimulation can be discontinued or weakened if the levelof diuresis is satisfactory (for example 1 cc/kg/min), and commenced ifreduction of GFR is noticed (for example 0.1 mgdl increase in plasmacreatinine).

Acute renal failure is optionally first treated by determining andameliorating the cause of the renal function deterioration. Reno-renalreflex activation may be provided during the initial stages of renaldysfunction as determined by renal function and urine analysis. In someselected cases renal shutdown, for example by activation of thevesico-vascular reflex, may be preferable, for example duringintoxication with a substance that is known to affect the kidneys, thetreatment optionally coupled with dialysis to remove the offensiveagent. Monitoring of the patient and the treatment efficiency mayinclude body weight as proxy for fluid retention. In the case that bodyweight increases above desired, or if the patient exhibits other signsof hypervolemia/uremia (for example subjective or objective dyspnea,increase in serum creatinine and/or urea above preset value) thevesico-vascular reflex can be stopped and/or a reno-renal reflexactivated. Similarly, if the toxic material is removed from the body ordetoxified, vesico-vascular stimulation may be stopped. Stimulation ofthe reno-renal reflex may be discontinued or reduced if urine analysisreveals elevation of protein levels or appearance of casts indicatinghyperfiltration nephron damage. Optionally, renal blood flow isintentionally increased or decreased, optionally by renal vesselstimulation and/or renal nerve stimulation.

A rare, but lethal, hepatorenal syndrome can be managed for example byredirecting blood flow to the kidneys. In patients suffering from thissyndrome, weight, blood pressure and/or kidney function analysis areoptionally taken. Optionally the pressure in the splanchnic circulationis also measured, either directly or estimated based on clinical signs.Optionally, if kidney functions show progressive deterioration, thereno-renal reflex can be activated (or vesico-vascular reflex depressedor other method used), optionally to increase renal blood flow and renalfunction. The treatment may be discontinued when desired levels of renalblood flow is reached. If hypotension or portal hypertension is found,the reno-renal reflex may be activated together with systemic orsplanchnic vasoconstrictors or a surgical intervention to reduce theportal pressure. This treatment may optionally continue till systemic orblood pressure normalizes, or kidney function improves (for example, areduction of 0.2 mgdl in createnine levels).

In patients suffering from edema and/or ascites, body weight and renalfunction can be assessed for signs of reduced diuresis. The reno-renalreflex may be then activated to remove the excessive fluids.

For shock patients, it may be appropriate to increase the bloodpressure, increase peripheral resistance but preserve the renal bloodflow so as not to damage the kidneys. As mentioned above, a number ofpossible stimulation methods may be appropriate. The reno-renal reflexcan maintain renal perfusion, while vasoconstrictors or vesio-vascularreflex increase systemic blood pressure.

Women suffering from preeclampsia may benefit from activation of thereno-renal reflex. In these patients, blood pressure, kidney functionand the fetal distress signs are optionally assessed to decide upon thetreatment. If maternal and fetal status do not require urgent delivery,reno-renal reflex stimulation may be used, optionally to reduce bloodpressure and prolong the pregnancy. Monitoring may include bloodpressure and fetal sonography. The treatment may continue eitherintermittently when high blood pressure is determined, orintermittently, for example as a preventive treatment.

In cases of Dyspnea, high wedge pressure, diuretics are optionallyadministered for venous vasodilatation and a reno-renal reflex evoked tomaintain GFR.

In an exemplary embodiment of the invention, of treating hypertension, ashort term effect is lowering sympathetic drive. This can have an effectin seconds. On a longer term effect, of hours or days or weeks,reduction in sodium and fluid levels can reduce fluid volume in the bodyand blood pressure.

In an exemplary embodiment of the invention, restimulation at shortintervals is used to enhance and/or maintain the effect on thesympathetic system.

The described systems/methods can work together and affect working of acardiac pacemaker. One example follows. Activation of a reno-renalreflex is expected to reduce the whole body sympathetic activity. In anotherwise healthy individual, decrease of the sympathetic system leadsto reduction of the heart rate. In many cases of patients equipped witha pacemaker, the pacemaker determines the rhythm of the heart. To mimicthe correct physiologic response, the described device can optionallysignal the pacemaker to reduce the pacing frequency. In another example,the pacemaker and urinary stimulator together affect cardiac output by,for example, control of afterload or preload using the urinarystimulator with appropriate cardiac stimulation by the pacemaker.Optionally, during an arrhythmia or fibrillation, flow to the kidneys isshut down, for example, to improve flow to the brain.

Control Specificity

In some cases, a single stimulation location affects several kidneyand/or system function simultaneously. Optionally, two or morestimulations are applied together to result in a desired more specificeffect, with one stimulation modulating the other. Optionally oralternatively, some effects (e.g., the acute effect on blood pressurevs. change in GFR) have different time constants from others (e.g., dueto an inherently different time constant of the cause, such as the causebeing hormones or sympathetic activity and/or due to an effective timeconstant mediated by the activation of various homeostatic and otherfeedback controls of the body) and closing a feedback loop on one effectto reduce the efficacy of providing a second, undesired effect.

Optionally, one or more of the following methods are used to provideincreased specificity:

(a) The sympathetic drive to the kidney affects different aspects ofkidney function according to the strength of the sympathetic activity.Lowest strength triggers renin secretion (and thus elevates bloodpressure) stronger intensity reduces diuresis and natriuresis and thestrongest intensity leads to reduction of renal blood flow and GFR. Inan exemplary embodiment of the invention, the sympathetic control of thekidney is modulated together with another stimulation, thereby providingadditional specificity. Optionally, sympathetic drive is modulated bystimulating the carotid body (e.g., with a direct effect on renalnerves).

(b) Optionally or alternatively, cooling (e.g., with a contact cooler)or heating (e.g., with a contact heater) of the skin is used, withcooling generally increasing GFR on a transient basis and/or redivertingblood flow towards organs other than the skin.

(c) Optionally or alternatively, modulation of hepatic pressure (e.g.,by placing a constricting or valve in or on the portal vein orstimulating the splanchnic nerve is used, wherein increased hepaticpressure reduces renal blood flow.

(d) Optionally or alternatively, pressure is modified in renal veins(e.g., using a valve or an external constriction, such as an inflatableballoon), wherein increased renal venous pressure reduces renal bloodflow.

(e) Pharmacology can be used to provide addition effects or counteractsome effects of stimulation. For example, a reno-renal reflex may beevoked while providing vasoconstrictors for shock treatment, therebyavoiding kidney damage due to low blood flow. Optionally, kidney bloodflow is provided at an increasing or cycling amount, for example, with alowest amount provided when shock is first treated and then additionalblood flow provided after a time (e.g., 30-45 minutes), possibly only inan amount sufficient to prevent kidney damage.

Exemplary System Design

FIG. 4 is a schematic block diagram of a urinary system stimulationconfiguration 4300, in accordance with an exemplary embodiment of theinvention. It should be noted that the actual device may have adifferent design from the configuration described below. Rather, thisconfiguration is used to highlight various optional features which maybe provided in devices according to some exemplary embodiments of theinvention.

As shown, an exemplary design includes a circuitry component 80,transducers 78 (e.g., stimulating electrical contacts), one or moreoptional sensors 90 and/or various optional external elements.

Referring first to circuitry component 80, which is optionally providedin a housing, component 80 optionally includes a controller 84. Asshown, controller 84 can include an optional clock 85, a memory 86,optionally including a stimulation sequence table 4308, a processor 87and more permanent storage 88, such as flash memory. Optionally, storage88 is used to store a log, for example, a log of activations and/ormeasurements and/or of analyses thereof. Optionally or alternatively,processor 87 is provided as dedicated circuitry. Optionally oralternatively, memory 86 includes algorithms for analyzing sensor inputsand selecting a sequence from table 4308 and/or for calculating asequence to be applied. Optionally or alternatively, memory 86 includesa set(s) of stimulation and/or control parameters for controlling aplurality of parameters. Optionally or alternatively, the memoryincludes a plurality of application protocols. Optionally oralternatively, the memory includes possible ranges of stimulationparameters. Optionally or alternatively, the memory includes timesand/or events at which to apply certain stimulations. Optionally oralternatively, the memory includes a link between inputs and a diseasestate, and suitable physiological effect targets and/or stimulationsequences for certain disease states.

In an exemplary embodiment of the invention, controller 84 generates ortriggers a stimulation signal via stimulation circuitry 89, for example,a capacitor with a switch. Optionally, two or more sets of stimulationcircuitry are provided.

In an exemplary embodiment of the invention, one or more leads (4305,4304, 4306) are provided. Each such lead may terminate with a transducer(e.g., an electrode contact or thermal stimulator contact) 78. Varioustransducer and lead designs are described below. Optionally, a circuit79 is provided for evaluating the quality of the transduction and/ordelivery, for example, by monitoring lead and/or contact impedance. Anexemplary method of evaluating quality is described below.

In an exemplary embodiment of the invention, circuitry component 80includes a sensor and input processing circuitry 81, which, for example,processes input from one or more sensors 90 and/or input from one ormore inputs 4302. Some exemplary sensors and inputs and possiblefeedback mechanisms are described below.

In an exemplary embodiment of the invention, circuitry component 80includes a power source 83, such as a battery or a mains supply.Additional exemplary embodiments of power sources include a primarybattery, a rechargeable battery such as a lithium ion battery, anelectrolytic capacitor, or a super- or ultra-capacitor. Optionally,power (e.g., for operation and/or for charging the power source) isprovided by wireless coupling, for example, using an external powersource/recharger 77 and an internal power transmission module 76 forreceiving such power, for example, using inductive coupling coils, an RFlink, an optical link, and/or an ultrasonic link.

In an exemplary embodiment of the invention, circuitry component 80includes one or more communication modules 82, for communicating withexternal devices. Such communication can be, for example, wired, forexample, for sending or receiving signals from other implanted devicesor other out of body devices. In another example, circuitry component 80includes a USB connector for connecting to a computer. Optionally oralternatively, a wireless communication mode is supported, for example,using radio-frequency (RF) (e.g., a local link such as BlueTooth, Zigbeeor WiFi), optical coupling, thermal coupling, ultrasonic coupling orelectromagnetic coupling. In one example, the communication modulecomprises an inductive coil (not shown) for receiving and transmittingRF data and/or power, an integrated circuit (IC) chip for decoding andstoring stimulation parameters and optionally additional discreteelectronic components required to complete the electronic circuitfunctions, e.g. capacitor(s), resistor(s), coil(s), and the like.Optionally, the IC is used to generate stimulation pulses (e.g.,intermittent or continuous).

In an exemplary embodiment of the invention, communication module 82 andpower transmission module 76 are unified. In an exemplary embodiment ofthe invention, input(s) 4302 and/or communication module 82 are used toenter external data, for example, laboratory results from an externallaboratory or test unit 4320, for example, a unit which analyses urineand/or blood chemistry. Additional examples of externally entered dataare weight, medication ingestions and/or general feeling (headache,malaise, etc.).

In an exemplary embodiment of the invention, communication module 82 isused to connect to one or more programming and/or monitoring and/orco-operating systems. In some embodiments of the invention communicationis with other stimulator system(s), other implanted devices and/ordevices external to a patient's body using one or more differentcommunication protocols.

In one example, a laptop 92, a cellular telephone 93 or a miniaturizedcomputer or PDA 94 are used for programming circuitry component 80and/or monitoring its operation and/or generating commands thereto.

Optionally or alternatively, a pacemaker 4310 (or other cardiac controldevice) commands circuitry 80, is commanded by circuitry 80 orcoordinates therewith. In one example, a combined therapy is used forheart failure. In another example, blood flow to the kidneys is reducedwhen pacing is applied, to compensate for reduced cardiac output. Inanother example, circuitry 80 is disabled when a defibrillation signalis generated by device 4310. In another example, circuitry 80 sensespacing signals and uses such signals to decide on an operational modethereof. In another example, pacing rate is reduced when stimulation ofthe urinary system is used to reduce sympathetic drive. In anotherexample, pacing is used to increase cardiac output when vasodilatationis caused by urinary system stimulation.

Optionally or alternatively, a pacemaker or other controller for aheart, stomach and/or other organ shares components, such as a housing,a power supply, a controller and/or a communication module with aurinary system stimulation system. It is noted that in some embodimentsof the invention stimulation of the urinary system uses a periodicitywhich is significantly lower than cardiac pacing, for example, ½, ¼,1/10 or less or intermediate parts of the periodicity of cardiac pacing(typically 1-2 per second). Optionally or alternatively, the power usedfor the urinary system is lower than in the cardiac system.

This may be, for example, for one or both of two reasons. First, inpacing, “capture” by the heart is essential. In the urinary system,there is usually no immediate threat by missing a single activation.Second, in the heart, stimulation of a significant area of muscle tissueis often required. In the urinary system, in some embodiments of theinvention smaller areas and/or more sensitive tissue (e.g., nervereceptors) are stimulated. For example, the power of a single excitingstimulus train in the urinary system may be, for example, less than ½,¼, 1/10, 1/20 or intermediate portions of that used to capture a heartduring pacing of the left ventricle from the apex in the right ventricle(e.g., 5-8 mA for 2 ms). This may allow a longer battery life and/or theuse of smaller batteries.

In another example, multiple stimulation systems for a urinary systemare provided, for example, one system for nerves and one for ureters.One or both systems may be implanted.

In another example, stimulation system 4100 is part of (or receivesinput from) a homeostasis system, for example, as may be provided in anICU to control hydration levels and blood chemistry by, for example,providing medications or infusions depending on measurement of bodyparameters. In one example, circuitry 80 provides instructions to modifyfluid provision and/or provision of medication of blood components, foodor ions. Alternatively, an external system controls multiple fluid andchemistry modifying sub-systems, one of which is system 4100. Optionallyor alternatively, system 4100 is instructed to stimulate a reno-renalreflex if salt levels are up in the blood and/or if urine levels aredown.

In another example, a scale 4314, for example, a scale equipped with awireless transmitter is used to indicate to circuitry 80 a patient'sweight, which may be used to automatically change a fluid retentionschedule thereof.

In another example, system 4100 may include or be coupled to a urinesystem 4316, for example, for measuring urine flow and/or content. Suchmeasurements may be used to, for example automatically, modify systemoperation.

In another example, a lung-fluid monitoring system is used, for example,to provide feedback on ability of the system to improve fluid in thelung conditions and/or trigger an increase in renal output to reducefluid retention in the lungs.

In another example, system 4100 may include or be connectable to a longrange link, such as using a land line or a cellular communicationprotocol.

Exemplary Implantable Device

In some embodiments, circuitry component 80 is implantable. FIG. 6 showsan exemplary implantable system 60 in which a capsule 65 is providedwhich encloses circuitry component 80.

An electrical stimulator 66 (e.g., a lead 62 with a distal side 63 and aproximal side 64), terminates with one or more electrical contacts 64,and is coupled to system 60 using a connector 61, for example of a typeknown in the art, for example, with connectors to 2, 3, 4 or more leadsor other wires. Optionally, capsule 65 serves as a ground or otherelectrode. In an exemplary embodiment of the invention, contact(s) 64are adapted for coupling to a ureter, for example, as described below.

Capsule 65 can be of a design known in the art of pacemakers and isoptionally a pacemaker capsule including cardiac pacemaker circuitryprogrammed to provide stimulation as described herein.

Exemplary electrode and lead designs are provided below.

Capsule 65 is optionally made or coated with biocompatible materials,such as noble or refractory metals, materials or compounds, such asplatinum, iridium, tantalum, titanium, titanium nitride, niobium, oralloys thereof, or of a polymer. Optionally, capsule 65 is hermetic toliquid and/or vapor passage. Optionally, capsule 65 is designed topermit passage of electromagnetic (or other) fields used to transmitdata (including commands) and/or power.

The shape of the stimulator 60 is optionally determined by the structureof the desired anatomy, the surrounding area, and the method ofinsertion or deployment, and can be, for example, of a standardpacemaker for the heart, or an elongate element which does not interferewith bending of the body.

Exemplary dimensions of a housing are, for example, between 3-5 cm by3-5 cm by 0.5-1.5 cm. An exemplary volume is less than 30 cc, less than20 cc, less than 10 cc or intermediate volumes.

Exemplary Trans-Urethral Device

In some embodiments, circuitry component 80 is left outside the body.This may be the case, for example, if the stimulation is via atransurethral stimulator, but in other cases as well, for example asshown below.

FIG. 7 shows an optional embodiment of an electrical stimulator wherethe control circuitry is provided within an external unit 415. Unit 415is optionally connected to one or more optional electrodes, for exampleto an electrode lead 413, optionally coupled through a connector 414. Asshown, lead 413 is optionally integrated with a stimulator based on anureteral indwelling catheter 410 including one or more contacts, whichtypically lies in a ureter 411 between a urinary bladder 412 and akidney 416.

Other embodiments described below show embodiments where lead 413 ispart of an in-bladder device, such as a stimulator based on a Foleycatheter which is configured to electrically stimulate parts of thebladder, in particular a trigone area thereof.

Dimensions of an external stimulator control unit can be, for example,between 1-5 cm by 1-5 cm by 0.5-1.5 cm. Optionally, the unit iscylindrical and has a size of about 1-2 cm diameter and 3-5 cm inlength. An exemplary volume is less than 30 cc, less than 12 cc, lessthan 5 cc or intermediate volumes.

Exemplary Sensors

Various sensors may be used with a urinary stimulation system,including, for example, one or more of the following. It should be notedthere are various packaging options for the sensors. For example, thesensors can be packaged with circuitry 80. In some cases the sensors areconnected to circuitry 80 using a lead, optionally sharing a lead with astimulator. In some cases the sensors are connected using wirelessmeans. In some cases, the sensors provide their input via humanintervention. For example, the following types and exemplary sensors,while being only examples, may be used:

-   -   (a) Device functionality. Sensed signals can include impedance        measurements, optionally to determine contact efficiency between        electrodes and tissue. This sensor can help with performing        focal stimulation of selected region. Optionally the sensor is        connected to an output to the user indicating whether focal        stimulation can be commenced. Impedance sensing can be important        when both an anode and a cathode are in the bladder, whereby if        there is poor wall contact urine may short circuit the        stimulation. In some embodiments, at least one electrode is        outside the bladder and in contact with body tissue and not        urine.    -   (b) Urinary system physical behavior. Sensed signals can        indicate various aspects of urinary system behavior, such as        ureteral urine flow that can be optionally determined by a flow        sensor located inside or outside of the ureter, by ultrasound        (US) methods or by external device, as known in the art.        Ureteral motility/electrical activity can be used a proxy for        ureter urine flow, ureteral motility can be measured for example        by a pressure sensor located within or outside of the ureter.        Ureteral electrical activity can be detected by a sensor located        inside or outside of the ureter, in the bladder or in other        pelvic organs; ureteral electrical activity can be isolated from        other signals by a distinct signal shape, the vector of        propagation and/or signal frequency. Urine flow within the        ureter can be used as an indicator of stimulation efficiency or        need for a stimulation. Additionally, bladder volume can be        measured by ultrasound, by radio frequency radiation,        mechanically or electrically, for example by impedance. Bladder        pressure can be measured by intravesical or extravesical        pressure sensor. Optionally the pressure sensor is located on        the outside of the body part of the stimulation device. Bladder        volume/pressure can indicate efficiency of stimulation and/or        activation of the vesico-vascular reflex. In an exemplary        embodiment of the invention, urine flow is used to indicate low        kidney function, or efficiency of treatment. For example, urine        flow can indicate when additional stimulation should be given.        The sensor can be located within the lumen of the catheter.    -   (c) Kidney function. Sensed signals can include sensing of renal        blood flow, for example by electric, mechanic or ultrasound flow        meter located inside or outside or renal arteries or veins.        Additionally, renal blood flow can be measured        pharmacologically, as known in the art. Renal sympathetic        activity can be measured using renal nerve electrical activity        measurement or by measuring catecholamine levels, preferably in        the renal vein. Urine concentration or composition can be        determined by a sensor located within the urinary system (for        example ion electrodes to measure sodium and potassium) or by        external urine analysis. Sensing of GFR can be performed by        measurements of plasma/urine levels of inulin, creatinine, urea        or other markers as known in the art. Creatinine and urea can be        measured inside the body by dedicated electrodes, as known in        the art, or using suitable optical sensors. Additional sensed        signals may be hormone secretion from the kidney, from example        renin, CGRP or erythropoietin, optionally measured in the renal        vein or urine. Sensed signals can be used to indicate efficiency        of treatment, need for a treatment and/or as indication to the        user of a change in renal function. For example, a drop in the        sensed GFR above preset amount (for example 20%) may activate        stimulation of the reno-renal reflex.    -   (d) Cardiovascular parameters. In an exemplary embodiment of the        invention, the sensed signals indicate cardiovascular parameters        that may mirror cardiovascular function. For example, blood        pressure can be measured by a pressure sensor located in or on a        artery, optionally the renal artery or measured externally as        known in the art. An additional signal that may be measured is        blood flow, measured by a flow sensor. ECG signals, heart rate,        cardiac output and/or vascular resistance may be measured by        sensors located within or on blood vessels or optionally by        ultrasound sensors. Cardiovascular parameters can be used to        indicate efficiency of treatment, need for a treatment and/or as        indication to the user. For example, reduced blood pressure        sensing may suggest stimulation of the vesico-vascular reflex or        vasoactive substance secretion or elution into the body, for        example, using a medicament pump to pump this and/or other        medicaments under control of the stimulation system. Increased        blood pressure sensing may suggest stimulation of the reno-renal        reflex.    -   (e) Blood and systemic. In an exemplary embodiment of the        invention, the sensed signals indicate the status of body        systems, such as the blood, for example blood analysis        optionally performed on blood samples taken from the patient;        body temperature measured by internal or external thermometer,        optionally the thermometer is integrated into the stimulating        device; plasma and/or urine glucose levels, measured by internal        or external glucose meter; systemic sympathetic activity        optionally measured from plasma or urine catecholamine levels or        from electrical recordings of muscle twitching; input from        external fluid status monitoring systems and oxygenation level        optionally from a pulse oximeter. Sensing of these signals may        be used to direct treatment; for example, a change in liver        functionality may indicate progression of a hepatorenal syndrome        and can be used to start and/or modulate reno-renal reflex        stimulation.    -   (f) Indirect sensing. Sensing may include patient weight;        position of the patient; input from the patient about her well        being and motion of the patient. These external sensed signals        can be used as indicators of stimulation efficiency or a need        for a stimulation. For example, increase in body weight above        preset number in a CHF patient may be used a signal for        reno-renal reflex stimulation. An additional example is        movements of the patient which may interfere with the        stimulation/sensing of electrical signals (e.g., so        stimulation/sensing may wait for such movement to stop and/or        may be corrected for it).

Exemplary Control Loops

Stimulation system 4100, may be provided with one or more feedbackmodes, depending, for example, on its implementation and/or programming.In one example, system 4100 operates in an open loop mode. In such amode, the device is programmed to provide stimulation at set times,periods and/or other parameters. One example where this may be useful iswhen a patient is identified as having high fluid retention and system4100 is used to reduce fluid load by increasing kidney activity. Astandard protocol, such as application for 2-10 hours or 3-10 days maybe provided. In another protocol, chronic stimulation is used, forexample, for 2-4 months or 2-4 years. Optionally, even in an open loopmode, a safety feedback is provided to stop operation of system 4100 orperform a counter-operation and/or provide an alert if a safetythreshold is passed or a safety problem otherwise detected. For example,when the electrical charge provided by the stimulation may harm thestimulated structure. In one example, low renal blood flow, low bloodpressure or high blood pressure, caused by over stimulation is detected.Optionally, the maximum allowed renal blood flow and/or output are setand the system optionally applies a suitable stimulation or stopsstimulation if a threshold is passed. Such safety features may be usedwith other renal/urinary stimulation systems as well. Another exemplarymode is a semi-open loop mode, in which feedback is provided relativelyinfrequently, for example, once an hour, once a day, once a week or atintermediate length times. This may be used, for example, for bodyweight (optionally including an input for patient to indicate intake offood and/or fluid, which may be corrected for.

Another exemplary mode is closed loop mode, in which feedback isprovided on a time scale similar to the effect on the body system beingcontrolled by stimulation system 4100. For example, feedback on bloodpressure may be provided every minute. An additional exemplary closedloop may include measures to prevent patient dehydration and/orhyponatremia. Optionally, a manual input to the device is first madeindicating the actual vs. the desired weight of the patient, and/orplasma sodium levels. Optionally, the device has sensors to measureurine flow and/or urinary sodium concentration. By counting the amountsecreted it is possible to discontinue the stimulation when the desiredfluid removal is reached, or when the amount of excreted sodium may leadto hyponatremia. An additional exemplary closed loop may be an automaticstimulation of the reno-renal reflex when renal function deteriorates.Optionally, the device senses GFR or urine flow, for example once anhour. If renal function is reduced below some preset value, as sensed,the device may start stimulation of the reno-renal reflex, optionallyuntil renal function improves. An additional exemplary closed loop maybe an enhancement of a naturally occurring reno-renal reflex. It ispossible that in patients suffering from hypertension the reno-renalreflex may not be functioning sufficiently to excrete fluid and sodiumfrom the kidneys. Optionally, stimulation of the reno-renal reflex maybe imitated when a natural stimulus of reno-renal reflex activation,such as increased urine flow or urine sodium levels are detected by thesensory element. The benefit from this method of stimulation may be amore physiological activation of the reno-renal reflex as needed forexample when the patient consumed large amount of water or sodium.Optionally, the sensing includes bladder volume/pressure sensing andinhibition of the vesico-vascular reflex to prevent activation of thesympathetic system. In one example, closed loop operation is pre-limitedto a certain time frame and/or to a certain number ofmeasurement-stimulation cycles. It is note however, that in general,system 4100 need not take a measurement before each stimulation event.For example, measurements values can be estimated instead of measuring,or feedback may be defined to be taken periodically or on some otherbasis.

In an exemplary embodiment of the invention, a stimulation sequenceparameter set includes one or more of stimulation sequence, desiredshort and/or long term effects, safety parameters of one or morephysiological sensors, a feedback mode and/or a logic for determiningand acquiring feedback or further instructions.

In an exemplary embodiment of the invention, the mode of operation takesinto account a residual effect of stimulation. As shown below somestimulations have an effect on kidney function lasting at least up toseveral hours after application. Such stimulation sequences may beconsidered to be inherently open-loop or semi-open loop. In some cases,such effects are counteracted by additional stimulations, if limitationthereof is desired. Optionally, the stimulation applied depends onpatient specific parameters, for example, cardiac output. This may beinstead of or in addition to setting of safety parameters such asthreshold amounts of change in blood pressure.

In an exemplary embodiment of the invention, reflexes are controlleddirectly. For example, a base-line activity of a reno-renal reflexand/or a vesico-vascular reflex may be measured directly, for example,by measuring nerve activity or indirectly by measuring effect.Optionally, a control loop is closed by the stimulation system raisingand/or lowering a level of activity of the reflex, for example, bystimulation of receptors and/or nerves involved in the reflex. In someembodiments, this is an example of external control of an existingcontrol loop. In some embodiments, the control is instead of diminishedbody control.

In some embodiments of the invention, information or commands to closethe loop are provided externally, form a user. For example, a user canindicate when a feeling of malaise starts and when it finishes.Optionally, the control circuitry may be configured to modify and/orotherwise process user input. For example, even if a user indicates tostop stimulation, the circuitry may continue stimulation, for example,to provide an easing off, or if measured parameters indicate acontinuation and/or changing of stimulation.

FIG. 8 illustrates a feedback process in accordance with an exemplaryembodiment of the invention.

At 100, a mode of operation (programming or non-programming) isselected, for example, based on an internal command or an internalprocessing.

In an exemplary embodiment of the invention, when in non-programmingmode an external and/or internal signal and/or parameter optionallyindicating biological status or response to stimulation is received at101 (e.g., feedback or command). The signal or parameter received isoptionally analyzed at 102 and a desirable stimulation (e.g.,excitation) signal is determined. Optional adjustment or determinationof algorithm parameters (e.g., stimulation parameter set) may also bedone at 102.

In an exemplary embodiment of the invention, at 103, a sub-mode ofoperation is determined, diagnostic, working or monitoring. When in adiagnostic mode (104) the signal(s) and/or parameter(s) received areoptionally communicated and/or logged. When in a monitoring mode (106)the signal(s) and/or parameter(s) received and/or the parameters thatare the result of the analysis done by system 4100 are optionallycommunicated and/or logged. When in working mode (105) the stimulationsignal is induced. Optionally the signal(s) and/or parameter(s) receivedand/or induced are communicated and/or logged. Following signalinduction the algorithm parameters may be adjusted according to thestimulation induced and/or its effect (107). Other exemplary feedbackmethods which may be used together or instead, are described herein.

When in a programming mode (108), system 4100 optionally receivesparameters in stage 110 and/or communicates parameters in stage 111optionally as part of a recurring loop (109). When programming iscompleted, system 4100 optionally receives an external signal (112)causing a switch to working mode (113) and optionally a return tolistening (100).

Optionally, when no external or internal signals are received toindicate otherwise, system 4100 passes from 100 to 101 automatically.

Exemplary Stimulation Modalities

While electrical stimulation is preferred for some embodiments of theinvention, other stimulation modalities are provided in accordance withsome embodiments of the invention. It is a feature of some embodimentsof the invention that stimulation affects various receptors in theurinary system, for example, afferent nerves, pressure receptors and/ortension receptors. It is a feature of some embodiments of the inventionthat stimulation is used to trigger an existing reflex, rather thancontrol a process. These two features, together or separately, can makeit useful to use non-electrical stimulation, which is less specific withrespect to magnitude and/or more specific with respect to receptorsbeing triggered.

In one example, afferent nerves are stimulated using light, chemicals,ultrasonic vibration and/or heat.

In another example, mechanical receptors are triggered by stretching,pressure or vibration. For example, expanding an object in a ureter cansimulate blockage of the ureter by a reno-renal reflex. Such expansion,for example as shown below, need not block the ureter, but can be usedto selectively reduce output from the “blocked” kidney and/or increaseoutput from an opposite kidney.

In an example of chemical stimulation, chemical stimulation of thereno-renal reflex can be by saline, potassium, hydrogen ions (low pH)and capsaicin to the ureter or bladder. Chemical substance can bereleased by perfusion from a nephrostome, ureter catheter,bladder-dwelling stimulator and/or implanted container. In an exemplaryembodiment of the invention, chemicals are released via one or morepores (e.g. 1-10) each having a surface area of between, for example,0.1 square mm to 1 square mm. Optionally or alternatively, chemicals areeluted, for example, using iontophoreses or other electrical drivingscheme, for example, from a gel, solid or hollow storage element,optionally using an electric field which causes stimulationintentionally or a field which does not. Optionally or alternatively,chemicals are provided using a pump. Optionally or alternatively,chemicals are released using a sustained release method and/or chemicalmatrix, as known in the art for drug delivery methods.

One option for a chemical stimulation of the bladder is intermittent(e.g., each “puff being, for example, 1-5 minutes and spaced apart 1-3hours) puffs of capsaicin to the trigone by a Foley like device withdelivery element close to the trigone, arranged similar to theelectrical contacts. Optionally or alternatively, stimulation of therest of the bladder, possibly with longer duration is used to reducevesico-vascular reflex. It is expected that a capsaicin puff will leadto desensitization of the receptors, which may be good for reducingvesico-vascular reflex.

In an example of mechanical stimulation in the ureter, mechanicalstimulation is optionally intermittent, as chronic dilatation of theureter may result in refractoriness, with the ureter possibly expandingto a larger volume.

Optionally, the ureter is expanded by a balloon. Optionally oralternatively, the trigone is mechanically activated by one or both ofan additional balloon (on the bladder filling balloon) and/or a stiffmechanical element that is moved by an external or an internal engine orby magnetism.

Specific examples of non-electrical stimulators are provided below.

Exemplary Stimulation Parameters

Before relating to specific stimulation parameters, it is noted that astimulation sequence may be applied in response to an event, in responseto a command and/or in response to a time. Further, the sequence appliedmay be modified, for example, based on a history of application, adesired long term effect and/or based on a physiological (or other)input. Such variation can also be applied to a continuously appliedstimulation sequence. It should also be noted that a stimulation of theurinary system and/or the body may involve multiple stimulators, eachsuch stimulator being controlled as described herein, optionally, butnot necessarily, in a synchronized manner, with known delays and/orsynchronized to events or sensed values.

In an exemplary embodiment of the invention, various applicationparameters as described herein are applied and/or modified automaticallyby the control circuitry of system 4100.

Referring now to an arbitrary stimulation sequence (e.g., electrical,but possibly other modality as well). A sequence can have a length of,for example between 0.01 seconds and 2 hours, for example, between 10seconds and 19 minutes, for example, about 10 minutes long. Optionally,such a sequence comprises a train of pulses or a long pulse or a seriesof sub-trains of pulses, with delays there between. Within a sequence,there can be, for example, a plurality (e.g., between 1 and 100, forexample, above 4 and/or below 30) of different pulses and/or sub-trains.In an exemplary embodiment of the invention, the actual stimulationparameters used are varied to reduce adaptation, habitation and/orperceptible and/or painful sensations. Optionally, a set of 2-20 (e.g.,3-4) or more different sequences with a same expected effect are cycledto reduce such habitation.

In an exemplary embodiment of the invention, pulses and/or sub-trainsand/or sequences are charge balanced (e.g., bi-phasic) and/or designedso that there will not be too much charge asymmetry in a given period oftime.

In an exemplary embodiment of the invention, delays between sub-trainsand/or between applications of sequences are selected according to oneor more consideration, for example, continued effect of a stimulationafter it stops, desired for tissue to recover, desire for tissue toapply other, uncontrolled functionality and/or desire for tissue toreturn to a baseline so that baseline can be measured.

In an exemplary embodiment of the invention, a single pulse can have asingle frequency, for example, between 0.1 and 100 kHz, for example,between 5 and 1 kHz, for example, between 20 and 100 Hz. Optionally oralternatively, a pulse may be a combination of frequencies, for example,two, three or more frequencies. In an exemplary embodiment of theinvention, a pulse has an energy of between 0.00001 Joule and 0.1 J. Inan exemplary embodiment of the invention, a sequence has an energy of0.001 Joule and 10 J, for example, between 0.01 and 0.1 Joule. In someembodiments, pulses are generated by a voltage source and the voltage ofa pulse is between 0.5 Volt and 100V, for example, between 1 and 10Volts. Optionally or alternatively, a pulse may be generated by acurrent source and its current set to be between 0.1 mA and 100 mA, forexample, between 1 and 10 mA. Allowed parameters may depend on thefrequencies, contact area and/or desired effect.

In an exemplary embodiment of the invention, stimulation is provided insessions that total at least 2 hours, 3 hours, 5 hours or intermediateor longer times a day. Within such a session, there may beinter-sequence delays. Optionally, such a session is repeated at leasttwice a day and/or at least 3 times in three days.

In an exemplary embodiment of the invention, delays between stimulationsare selected to reduce pain and/or sensation, while still providingeffects as described herein. For example, stimulation signals with alasting effect may be used so that stimulation is less continuous.

In some cases the stimulation depends on the frequencies and thewaveform of the stimulation. For sinusoidal stimulations, the efficacyof stimulation may be higher for low frequency stimulation (for example5-250 Hz). The stimulation intensity is, for example, up to 1.5 mA for 5Hz and 2.5 mA for 250 Hz. Optionally, an absolute threshold stimulationintensity is about 10 mA for all frequencies as this may cause pain.Other thresholds may be provided as well. In some cases, higherstimulation frequencies require higher thresholds of stimulations, forexample, at 2000 Hz the stimulations need to be about twice as powerfulas in 250 Hz to achieve a same effect. In some cases, stimulationfrequencies are selected to be frequencies that do or do not (or somelesser degree of selectivity) stimulate one or more of nerve tissuesmooth muscle tissue, sensory receptors and/or skeletal muscle.

For square pulses, much higher input can often be applied without pain.For square pulses, pulse width is optionally wider than 1 ms.Optionally, stimulation intensities can reach 10 times the values citedfor 250 Hz (e.g., 25 mA).

Optionally, the pain is adjusted for patient condition (optionallyautomatically by a programming system or by the stimulation system,optionally manually). For example, a patient with diabetes may havetwice the pain threshold. Optionally or alternatively, with age, forexample, between age 50 and 80, there is an increase in threshold of afactor of 2. Intermediate ages may have a threshold based on anassumption of constant reduction in sensitivity per year.

In an exemplary embodiment of the invention, 100 Hz continuous or 30seconds on/30 sec off stimulation is applied for durations of 30minutes. Shorter or longer durations and/or lower or higher duty cycles,for example, 90%, 80%, 60%, 50%, 30%, 20%, 10% or intermediate dutycycles within a sub-train of pulses and/or other frequencies may be usedin some embodiments of the invention.

In an exemplary embodiment of the invention, each pulse has a shapeselected from square-wave, rectangular wave, triangular wave, saw-toothand sinusoidal. Optionally, the leading angle is smaller (or larger)than the trailing angle. While the pulse may be bi-polar, optionally thepulse is unipolar. In some embodiments, the pulse is a DC pulse.Optionally, a DC baseline or other baseline is added onto the pulse.

In some cases a composite pulse is applied, for example, a first partstimulating and a second part modulating the effect of stimulation.Optionally or alternatively, a pulse has an FM modulation.

In an exemplary embodiment of the invention, the stimulation isenveloped, for example, convoluted with a low frequency signal, such asa sine wave or a sawtooth or a triangle envelope. Optionally oralternatively, the convolution provides a change in frequency over time,for example, a ratio of 1:1.1, 1:2, 1:4, 1:10 or intermediate or largeratios between different frequencies in different parts of a pulse.

While the pulses in a pulse train may be uniform, in some embodimentsthey vary, for example, there being an envelope which defines changes inamplitude and/or frequency and/or other pulse characteristics along thetrain and/or sequence. This may be useful to reduce adaptation. In somecases, the sequence is simply a single uniform pulse.

In an exemplary embodiment of the invention, the sequence is appliedusing bipolar electrodes. This may assist in locality. Optionally oralternatively, at least some sequences are applied using a unipolarelectrode with a common ground and/or using a pair of spaced apartunipolar electrodes. Such electrodes may be spaced apart, for example, 3mm, 1 cm, 2 cm, 3 cm or smaller or intermediate or larger distances.Optionally, the casing of an implantable stimulator system or anexternal electrode, acts as a return electrode. Optionally, a ground,common or return electrode is placed in contact with the suprapubicskin.

In some cases a therapy (or other application) includes applyingstimulation at a plurality of locations. Optionally, all such locationsare stimulated simultaneously. Alternatively, at least some locationsare stimulated after other locations. This may be useful, for example,to simplify power circuitry (e.g., using a switch between electrodesinstead of multiple electrode drivers). In another example, peristalsismay be encouraged using timed spaced apart stimulations along theureter.

In some cases, multiple sequences are applied together to obtain adesired effect, some of the sequences not being applied to the urinarysystem or being applied to different parts thereof. Optionally, suchsequences are applied together. Optionally, such sequences aresynchronized using a clock and/or sensing of an event.

In an exemplary embodiment of the invention, at least two sequences aredesigned to be applied at spaced apart times, for example, a pre-settime and/or based on measurements. For example, one sequence may cause afunction and another sequence may stop the function and/or otherwisemodulate it. For example, electrical stimulation may activate onereflex, optionally the reno-renal reflex, for example by a 5-1000 Hzpulses, and additional stimulation inhibit the vesico-vascular reflex,for example by a DC input.

In an exemplary embodiment of the invention, sensing is synchronized tosequence application, for example, being at a delay relative thereto orbeing timed to occur within inter-train delays in the sequence.Optionally, some sensing is done during or right after a sequence isapplied, for example, to measure the applied stimulation and/or itsdirect effect. In one example, sensing of nerve activity is providedwhile stimulating the nerve at a different location.

In an exemplary embodiment of the invention, sensing is separate fromstimulation. In other embodiments, sensing of electrical activitiesand/or electrode impedance and/or tissue interface quality uses the sameelectrodes as used for stimulation.

Exemplary parameters for non-electrical stimulation, above the abovedescribed pulse parameters, which apply to other stimulations include,for example: flow rate and concentration of chemical stimulants. In anexemplary embodiment of the invention, NaCl (or other sodium salt) at amolarity of, for example, 0.5M, 0.8M, 0.9M, 1.1M, 2M or larger orintermediate concentration is used to stimulate a reno-renal reflex.Optionally or alternatively, Capsaicin at 1 uM, 5 uM, 10 uM, 20 uM orsmaller, intermediate or larger concentrations is used in the ureterand/or bladder. The molarity used may depend on the chemical and itseffect on the targeted tissue and/or may be limited by toxicity.

For mechanical stimulation, pressure, in-tissue tension, vibration rateand/or amplitude may be controlled. In an exemplary embodiment of theinvention, mechanical stimulation in the ureter is by expansion of theureter and applies pressure of for example, 1-200 mmHg, for example,30-70 mmHg. A relationship between ureteral pressure and blood pressureis shown, for example, in the Schrum (1975) paper in the background.

For light stimulation, wavelength, power and/or energy density may becontrolled.

For thermal stimulation, temperature difference, temperature sign, areaand/or rate of temperature change may be controlled. For example,temperatures of 42 degrees Celsius may be used for exercitation.Temperatures of lower than 35, 32, 30 or intermediate degrees Celsiusmay be used for dampening excitability.

For acoustic stimulation, frequency, power and/or energy density may becontrolled.

Exemplary Usage Scenarios

In some embodiments of the invention, a stimulation system is implantedwhen its need is determined, for example, instead of providingmedication or as part of a global therapy, for example in patientssuffering from hyperactivity of the renal sympathetic nerves.Optionally, a minimally invasive system is used for a while (e.g., 2-10hours, 2-10 days or 2-4 weeks or intermediate times) to determinestimulation parameters and/or expected benefits. Optionally, a singlestimulation session is used to determine system suitability and/orinitial parameters.

In some cases, when in use, a system according to some embodiments ofthe invention reduces hospital stays, for example, by 20%, 40%, 80% induration and/or number and/or increases quality of life, for example, by30%, 50% or more. Desirably, a system according to some embodiments ofthe invention is used in a manner which reduces morbidity, for example,by 30%, 80% or intermediate or greater amounts.

In some embodiments the stimulation system, or at least a stimulatorportion thereof, is implanted by default, for example, being providedwith a Foley-like catheter which may also be used for urine collection.This may be, for example, in ICUs and in heart failure patients withacute events.

Temporary implantation may be useful also for in-ureter stimulators.

In an exemplary embodiment of the invention, implantation for animplanted device is by open or laparoscopic surgery used to connectstimulators to the outsides of structures (or to pierce such structures)and then implantation of a control unit (optionally in the abdominalregion, as for some pacemaker. For some embodiments of the invention, itmay be beneficiary to check proper device location and/or monitor aninsertion process by external means, for example by X-ray, CT, MRI orultrasound methods. Optionally, such input may be inserted manually tothe stimulation device, for example to change the location of thestimulation. Optionally or alternatively, optical means mounted on (orin) a stimulator and/or which carry the stimulator are used duringimplantation and/or at a later checkup.

In an exemplary embodiment of the invention, a trans-urethral device isinserted via a urethra, optionally without a cystoscope, into thebladder. A control unit may also be inserted (e.g., dwell in thebladder) or lie outside and connected wirelessly or by wire with theinserted stimulator portion. In an alternative embodiment, a stimulatoris inserted through the flesh of the pubic region into the bladder.

Optionally, once in the bladder, a stimulator may be left in thebladder. In some embodiments, the stimulator is a trans-ureteralstimulator which is advanced into one (or two ureters. Optionally, thestimulator is advanced into the kidney, for example, to reside in akidney pelvis thereof. Various attachment mechanisms for the stimulatorinside the urinary system are described below.

In another embodiment, a stimulator is inserted into a kidneytranscutaneously (e.g., using a nephrostomy procedure).

In another embodiment, implantation of the leads and a stimulator may beby a minimally invasive procedure. Optionally, the lead is introduced toand then out of the inside of a urinary lumen, for example a ureter by acystoscope and/or ureter catheter. Optionally, the lead pierces theureter or other urine carrying organ and is tunneled to a subcutaneousstimulator.

Optionally, the procedure is performed under imaging guidance, forexample CT, MRI and/or ultrasound. The target organ is optionally firstvisualized by the imaging technique, and then a lead is placednear/through or inside it by a minimally invasive method, as known inthe art.

In still other embodiments, the stimulator is mounted on a vaginal orrectal tampon and resides in the rectal or vaginal area. Alternatively,the stimulator is inserted past the rectal and/or vaginal wall, forexample, to closer approximation with the urinary tract. Optionally,vaginal, rectal and/or trans-urethral insertion is used for treating anon-acute cardio-renal syndrome.

In another usage scenario, preventive treatment and/or ongoingintermittent treatment is provided. In this example, a patient visits aphysician periodically receives a short stimulation session (e.g., 15minutes or up to 3 hours) and is released home.

In an exemplary embodiment of the invention, the system includes one ormore controls control which allows a patient to reduce stimulation powerand/or effect and/or delay a stimulation responsive to the patient beingbothered by the stimulation and/or its effect.

In an exemplary embodiment of the invention, implantation is sometimesfollowed or preceded by a calibration act. Optionally or alternatively,calibration is repeated as the patient's physiological state changesand/or as device shifts and/or otherwise interacts with the body. In anexemplary embodiment of the invention, such calibration includesapplying a series of stimulations and/or stimulation combinations anddetermine a response of the body thereto. Optionally, the body is placedin a certain physiological state for some such stimulations, forexample, using medication or diet. Optionally, the device is programmedwith the results of such calibration and/or with a set of stimulationsequences and/or “case-stimulate” pairs, according to the stimulationresults. Optionally, an initial programming includes determiningspecific safety problems for the patient and selecting sequences morelikely to avoid such problems. Optionally, the stimulation sequencesprogrammed include desired long term effects. Optionally, thestimulation sequences are programmed to change as time goes on and/or asphysiology changes and approaches a desired outcome and/or approaches anundesired outcome. For example, more gentle stimulation may be appliedas long as renal functions are above one threshold and strongerstimulation if baseline renal activity goes below such a threshold.

In an exemplary embodiment of the invention, calibration is fast (e.g.,with a round lasting 1-20 seconds or 1-5 minutes), for example, usingpatient feedback on nervous effects as sensed by the patient, or basedon sensing signals.

In an exemplary embodiment of the invention, the device is configuredfor diagnosis and/or includes a diagnosis-related display, for example,showing one or more stimulations used and their effects on one or moreparameters. Such a device can be an integral device or a two part device(stimulator and controller).

Diagnosis of nervous function in a patient may be assessed for exampleby providing a stimulation and observing whether the stimulation inducesor reduces bladder and/or sphincter contractions. Optionally, theinformation obtained by such means may be used to track a progression ofa nephropathy in a diabetes patient.

In hypertension patients, stimulation may be used to diagnose the originof the disease. For example, stimulation of a reno-renal reflex andmeasuring urine flow, natriuresis and/or blood pressure of a patient. Inpatients suffering from a hypoactivity of the reno-renal reflex suchstimulation may have a significant effect on these parameters. Inaddition, hyper activation of the vesico-vascular reflex may also be acontributing factor to hypertension. Activation or depression of thevesico-vascular reflex by stimulation of the bladder or afferent nervescan be used for diagnosis of such hyper activation and the treatment maybe to provide a chronic stimulation to inhibit the vesio-vascular reflexor amending the clinical condition contributing to said reflexactivation, for example treating bladder neck obstruction in patientssuffering from an enlarged prostate.

Exemplary Lead Properties

Many of the exemplary leads described below fall under two maincategories—leads outside urinary tract and leads inside urinary tract.In general, electrical leads outside urinary tract can be of any designknown for stimulator leads in the art, concerning, for example,flexibility, diameter and biocompatibility. A specific issue for leadsattached to the urinary tract is that the bladder and ureters move, forexample, due to muscular action and due to changes in patient postureand/or digestion, as well as other motion causing events. Optionally,the lead is soft enough and/or has a large enough diameter to avoiddamaging nearby tissues. In an exemplary embodiment of the invention, alead length is between 1 and 50 cm, for example, between 7 and 25 cm.Optionally, the lead is axially elastic, for example, having anelongation of 20% without damage.

For non-electrical stimulation, the lead optionally delivers electricalpower to a suitable transducer. In some embodiments, the lead includes alumen or two lumens for delivering and/or circulating a fluid and/orchemical to a suitable transducer.

For leads inside the urinary tract, chemical resistance to urine isoptionally provided, for example, using suitable coatings, such assilicone. Optionally, such an indwelling lead is hollow, to allow urineflow therethrough. Optionally or alternatively, the diameter of the leadis small enough to allow urine flow past. Optionally or alternatively,the lead shape (e.g., including a groove) is elected to support urineflow therepast. Optionally, urine flow is supported in kidney, ureter,bladder and/or urethra, as appropriate.

In an exemplary embodiment of the invention, the lead is thin enoughand/or soft enough to not interfere with valves in the ureter, valves inthe bladder and/or urine gating mechanisms of the bladder.

In some embodiments, no lead is provided, rather, power is transmittedto the transducers of the stimulator.

In an exemplary embodiment of the invention, the lead body is a coil ofmetal covered by a biocompatible layer, with the coil providingresistance to breakage and/or flexibility.

In an exemplary embodiment of the invention, a lead is formed of astainless steel coil and coated with a polymer.

In an exemplary embodiment of the invention, a lead electrifies between1 and 10 contacts. Optionally, each contact is separately electrifiable,or at least 3 or 5 contacts are separately electrifiable. Specificexemplary lead designs are provided below.

In an exemplary embodiment of the invention, the lead and/or otherelongate elements described herein, have a length:width (or diameter)ratio of better than 2:1, 4:1 10:1, 20:1 or intermediate ratios.

Exemplary Electrode Contact Construction

In an exemplary embodiment of the invention, a lead terminates in and/orhas one or more electrode (or non-electrical transducers) contacts alongits length. In some embodiments, the contacts are arranged in a line.Alternatively, the contacts may be arranged in a two dimensional array.Optionally or alternatively, the contacts are arranged in the shape ofan outside of a cylinder (e.g., for intra-ureteral stimulators) or acone (e.g., for kidney pelvis stimulators).

Optionally, the contact design provides anchoring, for example, a stentlike anchor in a ureter or a pig-tail screw-in tip for muscular tissue.Alternatively, the lead or other means provides anchoring. For example,a double pig tail ureteral design may anchor a lead with contacts in aureter. Exemplary contact shapes include, springs (e.g., for lodging ina ureter), discs (e.g., for contacting a trigone area), spheres, (e.g.,for contacting intra-kidney structure). Optionally, multiple contactsare provided adjacent to each other, for example, as concentric rings orspirals or springs, for example, to provide bipolar stimulation, e.g.,with each conductor coupled to a different wire in a lead.

In an exemplary embodiment of the invention, the contact design and/oranchoring mechanisms are selected so as not to interfere with naturalmovements of urinary system components, in particular flexing of uretersand peristalsis. As shown below, this may be achieved, using a flexiblecontact.

In an exemplary embodiment of the invention, contact area between anelectrical contact and tissue is between 0.1 square mm and 20 square cm,or smaller, intermediate or larger areas, for example, between 1 squaremm and 3 square cm. Optionally or alternatively, contact area betweenthe contact and body fluids is increased by using a porous coating toincrease surface area and/or reduce impedance. Optionally, the surfacearea of the target covered is between 1% and 90% of its area, forexample, between 3% and 10% thereof.

In an exemplary embodiment of the invention, the contact is made of orcoated with one or more of a conducting material as is known andaccepted in the art or other conducting materials, for example includingbut not limited to stainless steel, nitinol, platinum, iridium,tantalum, titanium, titanium nitride, niobium, or alloys of any ofthese, conducting silicone or other soft conductors and/or a capacitivecoating.

In an exemplary embodiment of the invention, a multi-point electrode ormesh electrode is provided for contacting a part of the outside of thebladder, optionally at a trigone area. Optionally, the mesh is definedwith one or more slots for receiving the ureters. Optionally oralternatively, such a mesh, optionally rolled into a cylinder, is usedfor stimulating the outside of a ureter. Optionally, such a mesh hasdimensions of 1-3 cm by 0.5-3 cm.

Exemplary electrode designs and/or their combination with various leaddesigns and/or suitability for various targets are described below.

As used herein, the term “coat” does not necessarily relate to theprocess of coating, but to a physical design in which there is aconducting portion or surface adjacent or overlaying a non-conductingsurface. For example, an insulation covered wire which includes a bareportion, maybe considered to include a conducting area coated thereat,in some embodiments of the invention. In some embodiments, a contactwould be attached or otherwise mounted at the bare portion. It should benoted that in some embodiments of the invention, conducting portions maybe conducting to only DC (e.g., of a certain polarity) or only AC (e.g.,of certain frequency ranges).

Stimulation Localization

A particular feature of some stimulation targets is that they arelocated in the abdominal cavity or the groin area where there are manystimulatable tissue regions and there is a potential for stimulatingunwanted tissue. Some embodiments of the invention deal with this issueby stimulating within lumens or within walls of urinary system elements.In some embodiments of the invention, bi-polar electrodes are used sothat the field at a short distance from an electrode contact is low.Optionally or alternatively, the electrode contact area is shielded, forexample, using a ground electrode and/or using an isolating layer, sothat electrical fields do not extend in unwanted directions for example,it may be desirable to focus stimulation so that at least 50%, 70%, 80%,90% or more is focused at a target, for example, in a spatial angle ofless than 90 degrees.

In some cases, an external common electrode, possibly the casing of thestimulation circuitry housing, is used.

Exemplary Bladder Stimulation Systems

As noted above, in exemplary embodiments of the invention, thestimulator resides in the bladder and is used to stimulate the trigonearea or distal ends of the ureters and/or, optionally, other parts ofthe bladder. In an exemplary embodiment of the invention, suchstimulation can be used to activate or depress a reno-renal reflex or avesico-vascular reflex. In a particular embodiment, a trigone area isstimulated to increase excitation thereof. Optionally or alternatively,the trigone area is stimulated to reduce sensitivity thereof. Optionallyor alternatively, the rest of the bladder is stimulated. In some cases,a stimulator is designed specifically to stimulate only parts of thebladder that are not the trigone.

In an exemplary embodiment of the invention, stimulator includes aballoon or other expandable structure. Optionally, the structure isdesigned so as to automatically position a stimulator contact in contactwith a trigone area or other desired location. A typical trigone istriangle like with a base of 2-3 cm and a height of about 1.5 cm.Optionally, the stimulator includes multiple contacts and an optionalmechanism for selecting which contact to activate. Optionally oralternatively, the contacts are designed to be local in effect, forexample, by ensuring contact with the bladder wall and/or by usingbi-polar electrification.

Optionally, the structure is rotationally symmetric. Alternatively, thestructure is asymmetric.

In an exemplary embodiment of the invention, the structure is designedto overcome deformations of the bladder, caused, for example, by anenlarged prostate or organ prolapse. Optionally, the structure ismanipulatable and/or comes in several sizes.

FIGS. 9A-9C are cross sectional views of female pelvic structures (butmay also be used for males) and the location of an intra-bladderstimulator 2106 in accordance with exemplary embodiments of theinvention. As shown in the figures, a typical female pelvis includes abladder 2101, a ureter 2102, a urethra 2103, a vagina 2104, a rectum2105 and a trigone area 2110 of the bladder.

Optionally, stimulator 2106 includes at least one electrode 2107,optionally designed to be in contact with a selected portion of bladder2101, for example, trigone 2110. As shown, in an exemplary embodiment ofthe invention, stimulator 2106 includes a bladder-dwelling balloon.Optionally, such a balloon is coated or is formed of and/or with ahydrophobic layer, which may improve electrical contact with the bladderwalls.

In an exemplary embodiment of the invention, according to FIG. 9Astimulator 2106 is inserted to bladder 2101 through urethra 2103. A wire2109, for example, extends from electrode 2107 to external stimulatorcontroller 2108.

FIG. 9B shows an alternative method of insertion of a stimulator 2106,through the skin. Optionally stimulator 2106 (optionally carried withina stiff channel and/or mounted on a sharp stylet), is inserted,optionally above the pubic bone 2120.

FIG. 9C shows an integrated device in which a small control circuitry2122 is integrated with a stimulator 2106. Optionally, circuitry 2122 islight weight and/or small. Optionally or alternatively, circuitry 2122includes a control knob (not shown), for example, for controlling anintensity of stimulation. Optionally, only a single control is providedfor circuitry 2122.

In an exemplary embodiment of the invention, circuitry 2122 includes anelectrode positioning and/or impedance sensing circuitry as describedherein. Optionally or alternatively, circuitry 2122 includes a feedbackdevice such as a light or sound generator (not shown). Optionally,feedback is provided if the system is unable to stimulate for a certainperiod of time.

In an exemplary embodiment of the invention, the device of FIG. 2106 isused by a user (e.g., a nurse) opening a sealed package and removing anisolating element (e.g., a battery disconnect) so that circuitry 2122 isactivated. Optionally, circuitry 2122 includes an integral battery whichlasts for several days or weeks. Optionally, the nurse adjusts thecontrol until a patient feels pain and/or until a desired outcome (e.g.,urine flow) is provided. Optionally, the nurse readjusts the settingevery few minutes, hours and/or days, according to results ofstimulation and/or patient sensation.

Optionally, circuitry 2122 includes a timer to limit the duration ofstimulation (e.g., to days or weeks). Optionally or alternatively,circuitry 2122 includes a sensor (e.g., urine flow) which is used toensure a safely level with respect to the kidneys, for example,preventing over stimulation thereof or starving thereof. For example, aurine outflow below a certain level may indicate low renal blood flow.

In an exemplary embodiment of the invention, circuitry 2122 includes aconnector (e.g., a USB connector) for programming a threshold and/orstimulation sequence and/or therapy plan into a memory thereof.

Optionally, the device of FIG. 9C is used to treat shock and ensure aminimal flow of blood and/or kidney function, e.g., by stimulation of areno-renal reflex, as needed.

In an exemplary embodiment of the invention, the balloon is notoverinflated to stretch the bladder. Rather the bladder is emptied so itcollapses. Optionally, several balloon sizes are provided, for example,for patients with distended bladders. In some embodiments, the balloon(or other expandable body, such as extendible arms) is inflated tointentionally activate a vesico-vascular reflex.

In some embodiments of the invention, the stimulation delivered dependson sensed signals, for example, signals indicating peristalsis orsignals indicating trigone activity. FIG. 10 is a block diagram of anexemplary stimulation system with feedback, in accordance with anexemplary embodiment of the invention. An electrical input from anelectrode 2201 is optionally amplified by a preamplifier 2202 and/or anamplifier 2203. Optionally, the amplified input is fed to a computer2204 (or other circuitry), optionally using an analog to digitalconverter 2205. Computer 2204 may optionally receive input from otherelectrodes 2206, optionally amplified and digitalized. According to oneembodiment of a feedback method, computer 2204 performs calculations atleast partially based on the input from electrodes. According to oneembodiment of a feedback method, the computer 2204 controls theelectrode to deliver the stimulation, the timing, the amplitude and/orother parameters of the stimulation. Such stimulation is optionallyprovided by a pulse generator 2207 and/or an isolator 2208. According toone embodiment of the invention, computer 2204 may control output ofmultiple electrodes 2209.

FIG. 11 is a flowchart of a method of selecting stimulation parameters,in accordance with an exemplary embodiment of the invention. At 2301, aninput from an electrode is received (e.g., at computer 2204). At 2303electrode impedance is optionally checked. If the impedance is low(e.g., lower than a preset value), it is often an error condition (2303)possibly indicating short circuit of electrical contacts by urine andthe user may be notified to readjust electrode position. In a mobilesystem, a sound may be emitted.

If the impedance is high, a determination may be made to see if theelectrode is at a correct location. For example, at 2304, urethra,bladder and/or ureter EMG may be searched for. A measured signal may bestored (2305). Optionally or alternatively, measured signals may beanalyzed to determine their parameters (2306), optionally by averagingwith previous measurements (2307). Data from other electrodes may beprovided (2206) and compared to the current data (2308). If enough datais collected (2309) an electrode which shows signal characteristicsclosest to those of the desired target position is optionally determined(2310) and optionally stimulated (2311). Alternatively, a user may benotified to wait until an electrode is selected (2312). Optionally, theresults of a stimulation are monitored to determine if the stimulatedtissue reacted as expected. If not, this may indicate incorrectstimulation or incorrect tissue. Optionally, such comparing is bycomparing to a complication, such as a table of expected results and/orranges of signal parameters.

Such methods may also be used for stimulating in other parts of theurinary system and for stimulating using non-balloon stimulators.

In an exemplary embodiment of the invention, a circuit for detectingcorrect placement of electrodes is mounted on the stimulator and forexample for a patient which can configure and/or apply stimulation byhimself or by a caregiver, for example, at home or in an old-age home;the patient can be notified (e.g., LED color) if he can stimulate and/orif a stimulation is expected to operate correctly.

FIG. 12 illustrates an intra-bladder stimulator 2106 with recordedphysiological signals, in accordance with an exemplary embodiment of theinvention. According to one embodiment stimulator 2106 is based on amodified Foley catheter (e.g., has similar dimensions and softnessand/or may be made by retrofitting a Foley catheter with severalelectrodes).

In an exemplary embodiment of the invention, a distal part 2401 ofstimulator 2106 lies in bladder 2101 and comprises an inflating balloonsection 2402. Optionally, stimulator 2106 has at least one electrode2107 attached in proximity to inflating balloon 2402. Optionally,simulator 2106 includes has at least one covering sheath 2403 locatednear insertion site of the balloon 2402 to catheter body optionally toease catheter insertion and prevent damage to the urethra by theelectrodes. A covering sheath may be used in other urethral (or other)insertions.

In this and other embodiments it may be desirable to empty substantiallyall urine form the bladder. Optionally, an aperture (e.g., 2410 as shownin FIG. 12) is provided adjacent the urethral exit (e.g., underneath theballoon, if any), to void urine and/or other fluids. Optionally oralternatively, the balloon forms on or more urine flow channels on itssurface.

In an exemplary embodiment of the invention, electrodes 2107 areconnected by conducting wires 2109 to a stimulation controller 2108,optionally located outside of the body. Optionally, controller 2108 hassensing capabilities, so that electric activity from electrodes 2107 canbe read out and analyzed. A display 2405 optionally associated withcontroller 2108 can is illustrated as showing signals measured form fourelectrodes 2107 (I-IV).

In an exemplary embodiment of the invention, using for example, themethods of FIG. 11, electrical activity of one or both ureters 2102, theurethra 2103 or bladder 2101 is analyzed by stimulation device 2108and/or compared (e.g., possibly by a human). In an exemplary embodimentof the invention, location of electrodes 2107 relative to structures ofone or more of the bladder 2101, the ureter 2102, ureteral orifice 2404,urethra 2103 are found by analysis of this electric activity. Trigone2110 may have its own unique electrical activity signature which can bedetected and/or stored by a system and used for estimating placement.Optionally, stimulator 2106 is repositioned (e.g., rotated or otherwisemanipulated) based on analysis of electric activity. According to someembodiments of the present invention, stimulation is performed by atleast one of the electrodes 2107 based on its location relative toone/both ureters 2102, urethra 2103, vagina 2104 and/or rectum 2105. Forexample, stimulation may be selected to have an intensity low as to notstimulate unwanted structure and/or to be large enough to reach nearbystructures whose stimulation is desired.

FIGS. 13A-B illustrate physiological signals recorded from the bladder,using the system of FIG. 12, in accordance with an exemplary embodimentof the invention. FIG. 13A provides an example of a 20-second-longrecording of an intra-bladder electric activity by an electrode locatednear the left ureteral orifice. In the graph are marked peristalticactivity of the left ureter 2501, peristaltic activity of the rightureter 2502 and contraction of urethra 2503.

FIG. 13B provides an analysis of the amplitude of an electrical signalof ureteral peristaltic activity from a 140 second recording. Amplitudedistribution clearly shows two peaks, indicative of different distancesfrom the two ureters. Optionally, if the device is equipped with morethan one electrode, stimulation can be provided by the electrode withthe highest recorded signals, optionally ureter signals. Alternatively,the device can be rotated and sensing continued, optionally till highersignal intensities are recorded. Optionally, stimulation can be providedto regions of lowest recorded activity, for example lowest urethrasignals, so as for example not to interfere with urethral sphincterfunction.

In a patient with an enlarged prostate (or organ prolapse), the bladderis distorted inwards near the urethra. This can make it more difficultto reach the trigone area with a regular balloon. In an exemplaryembodiment of the invention, balloons with a topology that bettermatches that of a distorted bladder are provided. Optionally oralternatively, other methods of avoiding or working around thedistortion are provided.

FIG. 14A-C illustrate an intra-bladder stimulation device designed forovercoming an enlarged prostate, in deployed and undeployed deviceconfigurations, in accordance with an exemplary embodiment of theinvention.

FIG. 14A shows a stimulator 2106, optionally suited for the malepopulation in accordance with an exemplary embodiment of the invention.In some cases of prostate 2601 hypertrophy, the lower segment of thebladder assumes a concave shape and the distal part of the ureter 2102and ureteral orifices 2602 may be located below the level of urethralsphincter 2603. In an exemplary embodiment of the invention, stimulator2106 has a non-spherical balloon 2402 that during inflated state comesin close proximity with bladder wall and/or ureteral orifice 2602 and/orintra-bladder part of the ureter 2102 and/or the trigone 2110, asdesired, and, in general, may better match the topology of the distortedbladder, for example including a concavity where the prostate would fit.

According to one embodiment the balloon 2402 is shaped like a spherewith concave depression 2604. According to one embodiment of the presentinvention, at least one electrode 2107 is attached in proximity to theinflating balloon 2402, optionally located near ureteral orifice 2602,intra-bladder part of the ureter 2102 and/or the trigone area 2110. Inan exemplary embodiment of the invention, the diameter of the concavity(e.g., in a plane perpendicular to the balloon diameter) is between 1and 4 cm, for example, 2.5 cm. In an exemplary embodiment of theinvention, an electrode (center) can be located, for example, justoutside (e.g., 1-2 cm outside) the concavity, on its rim and/or insidethe concavity.

FIG. 14B shows stimulator 2106 in a deflated condition, in accordancewith an exemplary embodiment of the invention. Optionally, deflatedballoon 2402 and electrodes 2107 are covered by a sheath 2606.Optionally, covering sheath 2606 can be removed from stimulator 2106. Inan exemplary embodiment of the invention, sheath 2606 is used to protectthe urethra and bladder from injury during the insertion of stimulator2106. Such a sheath may also be used in other embodiments of theinvention, especially if there are electrodes (or other non-smoothshapes), especially extending electrodes on the outside of the insertedstimulator.

FIG. 14C shows an alternative sheath design for a sheath 2403, inaccordance with an exemplary embodiment of the invention, in whichsheath 2403 is attached on both sides of the stimulator 2106 and slidesaway when balloon 2402 is expanded. In this way the stimulator 2106 isprotected both during insertion and during removal of the device.

FIGS. 15A-B illustrate multi-electrode intra-bladder stimulationdevices, in accordance with exemplary embodiments of the invention. Insome cases it may be desirable to stimulate large areas of the bladderor to select one of several electrodes to stimulate. The arrays shownhere can be mounted on other stimulator designs shown here. Optionally,as shown in FIG. 15A the electrodes (e.g., an array 2701) areconcentrated or provided only at a lower hemisphere of the balloon.Optionally, the electrodes are arranged in asymmetry relative to thetrigone, rather than the urethra. Optionally, the electrodes (2107) aremounted on leads or ribbons which extend along the axis of the balloonand do not interfere with its expansion. Optionally, such leads areflexible. Alternatively, there is no symmetry. FIG. 15B shows anembodiment where electrode array 2701 is provided as part of flexiblegrid 2702 in which multiple independent electrodes are optionallyintegrated.

FIGS. 16A-F illustrate an intra-bladder stimulator 2106 with extendingelectrodes 2022 and 2801, in accordance with an exemplary embodiment ofthe invention. In general, the electrodes are mounted on arms, whicharms are spread open and/or pushed against bladder wall tissue, byexpansion of the balloon. While the arms are shown slightly curvedinwards, in some embodiments, they curve outwards, to provide bettercontact, for example.

FIG. 16B shows stimulator 2106 in deflated state, in which electrodecontacts 2801 are substantially flush with the body of stimulator 2106and suitable for insertion (optionally a sheath is used).

FIG. 16C is a top cross-sectional view through the balloon, showing anarray, of, for example, 4 electrodes 2801. Fewer (e.g., 1, 2, 3, 4) ormore (e.g., 5, 6, 10, 12, 16 or more or intermediate numbers) electrodesmay be provided, for this and/or for other multi-contact and/or arraystimulators. Also, balloon 2402 (and, optionally the other designs shownherein) need not be rotationally symmetrical. Optionally, such asymmetryenables better contact of the electrodes to the tissue andprevents/reduces device rotation within the bladder. Also shown (FIG.16D) is the same cross-section in undeployed configuration.

FIGS. 16E and 16F show cross-sections of the shaft of stimulator 2106,according to an exemplary embodiment of the invention, showing aplurality of electrode leads 2026, a balloon inflation lumen 2025 and aurine flow lumen 2024. Optionally, an additional lumen (not shown) isused for irrigating the balder, for example, with nerve modifyingfluids.

FIGS. 17A-C illustrate an asymmetric intra-bladder stimulator 2106 withextending electrodes, in accordance with an exemplary embodiment of theinvention. In this design, balloon 2402 does not extend equally in alldirections. For example, as shown in a side view FIG. 17A and a topview, FIG. 17C, extension is one directional and serves to extend alimited number of electrodes at, for example, UVJ areas of the trigoneor ureteral orifice 2602. FIG. 17B shows stimulator 2106 when balloon2402 is uninflated. Optionally, such asymmetry enables better contact ofthe electrodes to the tissue (e.g., trigone) and/or prevent devicerotation within the bladder. It should be noted that such a designand/or asymmetry may also be used for balloons that have the electrodesmounted thereon and/or for other intra-bladder devices as describeherein.

It should also be noted that if the bladder is emptied, as it is in someintra-bladder devices of the invention, the bladder collapses on theballoon and asymmetry in the balloon design can assist in preventing ofrotation thereof.

Mechanisms other than balloons may be used to engage the bladder wallwith electrodes. For example, mechanical structures that deflect and/orexpand, may be used. FIGS. 18A-C illustrate a split-tip intra-bladderstimulator 2106, in accordance with an exemplary embodiment of theinvention.

In this stimulator, a tip 3001 of stimulator 2106 is configured to splitinto, for example, two or three parts 3002, with an electrode 3003associated with each part. Optionally, parts 3002 curve away fromstimulator 2106 and optionally back towards the urethral entrance.Optionally, they are preventing from curving by a sheath used duringinsertion. Alternatively, other bending mechanisms may be used, such asknown in the art. Optionally, stimulator 2106 is hollow so that urinecan flow between parts 3002.

FIG. 18C is a top view of stimulator 2106 located within bladder 2101.Optionally, the size and shape and/or other mechanical properties ofparts 3002 are selected so that electrodes 3003 (or at least one or twothereof) contact desired stimulation locations in the bladder, forexample, near the ureter 2103, ureteral orifice 2602 and/or the trigone2110. Optionally, the size and the shape and/or other mechanicalproperties are different between different parts 3002, so that currentorientation of the stimulator 2106 within the bladder 2101 ismaintained. For example, one or more of the parts 3002 can be longerthan the others, so that it can specifically point to the anterior partof the bladder 2101 and optionally assist in location and/or fixatingthe stimulator in the bladder.

Optionally, in some embodiments (this or other) of the invention,correct orientation is by including a mark on an extra-body portion andthe user orients this mark with an external anatomical landmark toensure correct orientation.

FIG. 19A-C illustrates an intra-bladder stimulator 2106 with radiallyextending electrode contacts 3101, in accordance with an exemplaryembodiment of the invention. Optionally, when deployed, the electrodescurve or bend back towards the urethral opening, so as to better contactthe trigone area in cases of enlarged prostate and/or organ prolapse.

In an exemplary embodiment of the invention, a wire 3104 or other typeof control, such as a cable, which optionally extends to outside of thebody, is used to retract a deployment mechanism 3102, optionally againstthe force of a spring 3103. Absent the pulling of wire 3104, spring 3103optionally collapses mechanism 3102 and the electrodes lie flat.Optionally or alternatively, wire 3104 also provides electrical power tothe contacts 3101. Optionally or alternatively, the spring is used todeploy the electrodes and the cable is used to retract the electrodes.In an exemplary embodiment of the invention, mechanism 3102 comprises aplurality of wires, configured to bend at electrodes 3101, which, whenshortened by having one end pulled towards the other, extend out of thesurface of stimulator 2106. Optionally, mechanism 3102 comprises atubular layer with multiple axial slots or slits formed therein.

FIGS. 20A-C illustrates an alternative pull-wire activated stimulator2106, in which pulling on a wire 3203 (or other control) causesextension of one or more electrodes. In the embodiment shown, one ormore electrodes 3201 are mounted on a flexible (and optionally elastic)wire 3202. In resting position, the wire may lie flat against stimulator2106. Pulling on wire 3202 approximates two ends of the wire, so thatits new resting position is with electrodes 3201 extended.

FIG. 20C shows stimulator 2106 in a bladder, showing electrodes 3201against desired stimulation targets.

When stimulating the trigone and/or ureters, stimulation from outsidethe bladder is optionally practiced. FIG. 21 illustrates stimulators forstimulating a urinary system from a vagina or rectum, in accordance withan exemplary embodiment of the invention. A vaginal tampon/probe 3304(optionally self-powered) can have one or more electrode contacts 3305(or other transducers) positioned thereon for stimulating a trigone, forexample. Optionally, such electrodes are used for detecting electricalactivity of targets, as described above, and for selecting an electrodeand/or stimulation properties thereof, accordingly.

A rectal probe/tampon 3306 with a similar electrode set-up 3307 is alsoshown and may be more suitable for male patients.

Also shown is a trans-pubic stimulator 3301, with a lead 3302 extendinginto the body (e.g., at the pubic area) into contact with a target area,and optionally including an anchoring portion 3303, for example, anintra-muscle screw, a clip or a suture. Optionally or alternatively, thestimulator passes through the bladder body to lodge in and/or contactthe trigone area. Optionally, the control circuitry is implantable.

It should be noted that in a supra-pubic approach, the location of aconcavity (if any) and electrodes will generally be at a distal side ofthe device, to match an expected point of contact with a trigone orother stimulation target. Similarly, while symmetry relative to thetrigone may be the same, symmetry relative to an elongate lead body maychange according to the insertion method.

FIGS. 22A-C shows an expanding in-bladder catheter design, in accordancewith an exemplary embodiment of the invention. The design of stimulator2106 in this figure illustrates two features which need not be providedtogether. A first optional feature is that balloon 2402 is asymmetric,as shown in FIG. 22C, it can have, for example, an ellipticalcross-section, or even a triangular cross-section, to match the shape ofthe bladder. This can reduce rotation and/or aid in positioning thereof.This may be in addition to or instead of an asymmetry (if any) caused byproviding a concavity at one side of the balloon. Another optionalfeature shown is having electrodes 2107 only on part thereof, forexample, on only one quadrant thereof, for example, on less than 50%,40%, 30%, 20%, 10% or smaller or intermediate percentages of surfacearea (as defined by the area of a convex polygon connecting theelectrodes). This may assist in limiting stimulation to a trigone area.

FIG. 23 shows an expanding in-bladder stimulator 2106 with a bendingshaft 5000, in a prolapsed female bladder 2101, in accordance with anexemplary embodiment of the invention. In the example shown, a femalewith a prolapse, the bladder is distorted. Optionally, a shaft 5000 ofstimulator 2106 is bendable, for example, using bending mechanisms knownin the art (e.g., pull wires attached to spaced apart points at itsdistal end) or using a stylet. Optionally or alternatively, such adesign has one or more electrodes reaching further up the balloon (e.g.,above a midline thereof), to compensate for the greater rotation of theballoon to ensue contact with a trigone area, for example.

FIG. 24 shows an expanding in-bladder catheter design (e.g., for exampleas shown in FIG. 14) with a concavity implanted in a male with anenlarged prostate, in accordance with exemplary embodiments of theinvention. A balloon 2402 with a concavity that is large enough (e.g., adepth of between 0.5 and 2 cm, for example 1 cm and a diameter between 1and 3 cm) to conform to a distance between a urethra 5101 and a trigone2110, distorted by a prostate 5100.

FIG. 55A presents a side view and FIG. 55B presents a front view of aninflated urinary catheter 7100 that optionally has one or moreexpandable parts 7101 and 7102, and a shaft 7110 (e.g., the catheter maybe a double balloon bladder catheter), in accordance with someapplications of the present invention. Optionally, at least some of theexpandable parts are connected to a pressure source via tubes 7103 and7104 so that the expandable parts can be inflated and deflated.

Optionally, urine drainage is facilitated via one or more urine-drainageholes 7105 and/or 7106, which are located proximally or distally withrespect to the expandable parts. Typically, the urine-drainage holes areconnected to a drainage channel 7107 in the catheter shaft. Optionally,an additional drainage tube and/or port 7108 is in fluid communicationwith drainage channel 7107. For some applications, drainage tube 7108 iscurved so as to facilitate urine drainage from the bladder even in thepresence of a deformation of the bladder, such as a deformation causedby a bulging prostate and/or a prolapsed bladder. Optionally, at leastone electrical contact 7109 is connected to at least one of theexpandable parts 7101 or 7102. The electrical contacts are typicallyused to stimulate at least a portion of the subject's bladder, asdescribed herein.

FIGS. 56A-B show an array 7201 of electrical contacts 7109 disposed onexpandable part 7102, in accordance with some applications of thepresent invention. Optionally, array 7201 includes a plurality ofelectrical contacts 7109, the plurality of electrical contacts beingindividually controlled. FIG. 56A shows expandable parts 7101, 7102 indeflated states, and FIG. 56B shows the expandable parts in inflatedstates.

As shown in FIG. 57, for some applications of the present invention, oneor more of expandable parts 7101, 7102 is connected to catheter shaft7110 at a connecting location 7302. For some applications, one of theexpandable parts is connected to the other expandable part at aconnecting location 7301. Optionally, the position of expandable parts7101, 7102 with respect to each other is controlled by the constitution,width, elastic properties or location of the expandable parts. Uponbeing inflated, expandable parts 7101, 7102 may rotate and/or changetheir position relative to the catheter shaft 7110. Optionally, theangle between the expandable parts 7101, 7102 may depend on the pressureor volume to which the expandable parts are inflated.

FIG. 58 shows catheter 7100 placed in a urinary bladder 7400 of a malesubject, in accordance with some applications of the present invention.For some applications, expandable part 7101 is inflated such thatelectrical contacts 7109 are in direct contact with a specific part ofthe bladder, e.g., trigone 7401, or distal part of the ureters 7402. Forsome applications, expandable parts 7101, 7102 are configured such thatcontacts 7109 (which are disposed on at least one of the expandableparts) are placed in contact with the trigone 7401, or distal part ofthe ureters 7402, in male subjects that have an enlarged prostate 7403.As shown, the expandable parts are configured such that contact betweenthe contacts and the trigone or distal part of the ureters is notimpeded by an enlarged middle lobe 7404 of the enlarged prostate. Forsome applications, contact between tissue of the subject and electricalcontacts 7109 is measured (e.g., by resistance or pressuremeasurements), and expansion of the expandable parts is performedresponsively to the measurements.

FIG. 59 shows catheter 7100 placed in a urinary bladder 7400 of a femalesubject, in accordance with some applications of the present invention.For some applications, expandable parts 7101, 7102 are configured suchthat contacts 7109 (which are disposed on at least one of the expandableparts) are placed in contact with the trigone 7401 or distal part of theureters 7402 in female subjects having aberrant anatomy, such as acystocele 7501 that prolapses to the vagina 7500. For some applications,contact between tissue of the subject and electrical contacts 7109 ismeasured (e.g., by resistance or pressure measurements), and expansionof the expandable parts is performed responsively to the measurements.

Reference is now made to FIGS. 60A-62C, which are schematicillustrations of respective cross-sectional views of catheter 7100.FIGS. 60A-B show longitudinal cross-sections of the catheter. FIG. 60Ashows a longitudinal cross-section along a central longitudinal line7701 of the catheter. The location of central longitudinal line 7701 isindicated in FIGS. 61A-C. FIG. 60B shows a longitudinal cross-sectionalong a line 7702 that is at a lateral location with respect to line7701. The location of line 7702 is indicated in FIGS. 61A-C.

FIG. 61A shows a transverse cross-section along a proximal transverseline 7603, FIG. 61B shows a transverse cross-section along a centraltransverse line 7602, and FIG. 61C shows a transverse cross-sectionalong a distal transverse line 7601. The locations of lines 7601, 7602,and 7603 are indicated in FIGS. 60A-B. FIGS. 62A-C show transversecross-section views of catheter 7100 along distal transverse line 7601.

As shown in FIG. 60A, for some applications, when not inflated, bothexpandable parts 7101 and 7102 do not protrude from the profile of thecatheter 7100, and are optionally located within the lumen 7107 (whichmay also function as the urine-drainage channel, as describedhereinabove). Optionally, tube 7104 is made of an elastic material, soit can expand when one of the expandable parts 7101 or 7102 areinflated.

FIGS. 62A-C show transverse cross-sectional views of catheter 7100,respectively, when expandable parts 7101 and 7102 are in deflatedstated, in partially inflated states, and deflated states thereof, inaccordance with some applications of the present invention. As shown,for some applications, when the expandable parts are in deflated states(FIG. 62A), electrical contacts 7109 are covered (e.g., engulfed) byexpandable part 7102. Optionally, this can reduce irritation to tissue(e.g., urethral tissue) of the subject during device deployment,relative to if the contacts were exposed during device deployment, thecontacts thereby contacting tissue of the subject.

FIG. 63 shows a longitudinal cross-section of catheter 7100 in thedeflated state, in accordance with some applications of the presentinvention. For some applications, at least one of expandable parts 7101,7102 covers at least a portion of shaft 7110 of catheter 7100. FIGS.64A-D show respective transverse cross-sectional views of catheter 7100,as shown in FIG. 63. The locations of the transverse cross-sectionalviews of the catheter that are shown in FIGS. 64A-D are indicated inFIG. 63 by lines A, B, C, and D, respectively.

FIGS. 65A-C show catheter 7100, expandable part 7101 of the catheterhaving at least one (and optionally, more than one) region 7800 havingvariable elasticity or width, in accordance with some applications ofthe present invention. FIG. 65A shows an application of the presentinvention according to which, during deployment of catheter 7100,expandable part 7101 and/or regions 7800 are covered by protectivesheaths 7801 and 7802. Optionally, upon expansion of the expandableparts 7101 and/or 7102, sheaths 7801 and 7802 are pushed back and exposeelectrical contacts 7109.

For some applications, region 7800 is a region of expandable part 7101that is characterized by being of greater thickness compared to otherportions of 7101. In accordance with respective applications of theinvention, the change in thickness of the expandable part at region 7800with respect to surrounding portions of the expandable part is gradualor discrete. For some applications, region 7800 is located near theconnection between expandable part 7101 and shaft 7110 of catheter 7100,as shown in FIG. 65B.

FIG. 65C shows catheter 7100 disposed in a bladder 7400 of a malesubject who has an enlarged prostate 7403, in accordance with someapplications of the present invention. For some applications, region7800 is more rigid (e.g., less expandable) than other parts of theexpandable part 7101. Region 7800 is configured such that upon expandingexpandable part 7101, region 7800 forms a concave dent in expandablepart 7101. For some applications, the concave dent enables theelectrical contacts 7109 to come into direct contact with ureter 7402and/or trigone 7401.

FIGS. 66A-B show catheter 7100, strings 7900 being located within one ormore of expandable parts 7101, 7102, in accordance with someapplications of the present invention. It is noted that for someapplications, strings 7900 are located outside of the expandable parts7101, 7102 (application not shown).

For some applications, strings 7900 are made of a material havingelastic properties that are different from elastic properties of thematerial from which expandable part 7101, 7102 is made. Optionally,strings 7900 are rigid. Optionally, strings 7900 and expandable parts7101, 7102 comprise the same material. For some applications, strings7900 are connected to the expandable parts 7101, 7102 at a region in thevicinity of a pole of the expandable part, e.g., in the vicinity ofbottom pole 7901 of expandable part 7101, as shown in FIG. 66A.Optionally, connection of strings 7900 to the region constricts theexpansion of the region of the part 7101, 7102 to which strings 7900 areconnected. For some applications, the strings are connected to theexpandable part such that upon expanding expandable part 7101, theregion to which the strings are connected forms a concave dent in theexpandable part 7101. For some applications, the concave dent enablesthe electrical contacts 7109 to come into direct contact with thesubject's ureters or trigone.

FIG. 67A shows a string 7950 connected to shaft 7110 of catheter 7100,in accordance with some applications of the present invention. For someapplications, the string is connected to shaft 7110 inside expandablepart 7101. Optionally, string 7950 can be pulled or released from a partof catheter 7100 located outside the subject's body. Optionally, uponpulling of the string 7950 the shaft 7110 of the catheter 7100 bends.Optionally, the bending of the shaft 7110 can be used to bring theelectrical contacts 7109 into close contact with trigone 7403 and/orureter 7402, as illustrated in FIG. 67B. Thus, for some applications, auser manipulates string 7950 from outside the subject's body, such as tobring the electrical contacts into close contact with a portion of thesubject's bladder.

In an exemplary embodiment of the invention, the electrodes used arebipolar electrodes. Optionally, electrodes which may remainfree-floating in the bladder (not in contact with wall) are madebipolar. This is useful, because the field which will then reach abladder wall at unintended locations may be small.

In an exemplary embodiment of the invention, stimulation of a bladder isprovided also, or only by providing a suitable chemical in the bladder.For example, a nerve stimulant or a nerve depressant may be injectedinto the bladder. Optionally, the trigone area is protected during suchinjection. A device such as described in U.S. Pat. No. 5,749,845 may beused for such injection and protection (with a possible modification byadding of a shield). Optionally, the trigone area is stimulated withelectrodes during or after such chemical treatment of the bladder.Optionally or alternatively, a protective layer, for example, a patch ofisolating material, or multi-layer element including a conductor may beused when stimulating the rest of the bladder (e.g., using a centralelectrode and an external electrode), or when ablating the bladder, forexample, using RF.

In an exemplary embodiment of the invention, after stimulating thebladder to determine effect of such stimulation, part of the bladder maybe ablated, so as to damage sensory nerve endings thereof. In anexemplary embodiment of the invention, such ablation and/or simultaneousstimulation of the bladder and the trigone areas may be used to achievea desired balance and/or replace a natural balance between a reno-renalreflex triggered by trigone stimulation and a vesico-vascular reflextriggered by bladder stretching. In an exemplary embodiment of theinvention, such stimulation (or ablation) of the bladder includesstimulation of, for example, 100, 80%, 50%, 40%, 30%, 20% or smaller orintermediate percentages of bladder surface area. Optionally, thebladder is intentionally stimulated to trigger and/or modulate thevesico-vascular reflex.

In one embodiment, parts of the bladder are stimulated to reducecontraction thereof and/or treated with a chemical which reducescontraction thereof, to counteract any unintentional effect ofstimulation of the trigone or ureters.

In an exemplary embodiment of the invention, the stimulator includes auser input for stopping stimulation during (intended) urination ordefecation. Optionally or alternatively, the stimulator (or a controllerthereof) detects such activity, based, for example, on change in postureand/or changes in EMG, and stops stimulation and/or effect assistivestimulation (e.g., to enhance bladder contraction).

In an exemplary embodiment of the invention, a balance between areno-renal reflex and a vesico-vascular reflex may be affected byreducing bladder filling (e.g., by lifestyle changes) and/or by removingor shrinking the prostate and/or opening the urethra. Optionally,shrinkage is provided using a medicament, such as an anti-androgen.

In an exemplary embodiment of the invention, a blood pressure treatmentand/or medicament includes an existing blood pressure controllingmedicament, such as a beta blocker, ACEI and ARBs, calcium channelblockers, diuretics and other medications as known in the art and aprostate shrinking, urethral opening and/or bladder draining medicament,such as an anti-androgen. Such medicament may be provided at apharmaceutically acceptable dosage and in a pharmaceutically acceptablecarrier, for example, for oral intake or for intravascular injection ortransdermal provision.

Other drug-device combinations are possible. In one example, a drug issold with a marker readable by the stimulation system (e.g., via abar-code reader or an RFID tag) so that the stimulation is adjustedaccording to the drugs taken by the patient. This may be useful, forexample in a hospital setting (or in a home setting with irregular drugtaking times and/or in a care center) where a drug packet can be swipedby a stimulation system and/or a programming system before it isadministered. Optionally or alternatively, a memory chip, for example,with a USB connection that can plug into the stimulation system and/or aprogramming system, is used. Optionally or alternatively, the drug issold with written instructions and/or a code to input into thestimulation system and/or a programming system, for example, via a userinterface, such as a mouse and keyboard (e.g., and display).

In an exemplary embodiment of the invention, the stimulation is used tocompensate for side effects of drugs, for example, increase kidneysympathetic activity to compensate for beta blockers or decreasesympathetic activity so as to reduce pro-arrhythmic effects of somemedication. In another example, higher amounts of diuretics may be used,if a reno-renal stimulation can be used to ensure minimal renal bloodflow. For example, high dosages of Furosemide, such as 100-500 mg can beprovided. In an exemplary embodiment of the invention, an otherwiselife-threatening amount of medication may be provided to a patient inneed thereof, using the stimulation system as a life-saving adjuvant.Optionally or alternatively, lower amounts of drugs are provided and thereminder of the desired effect is provided by stimulation.

Exemplary Lead Design

Various lead designs can be used. In particular, various lead designsknown in the art can be used. Optionally, the lead is selected accordingto the target and/or distance between the target and stimulator and/orexpected movement of the target and/or stimulator and/or according topotential to damage nearby tissues and/or according to it beingpermanently implanted or inserted.

It should be noted that while some stimulation methods described hereinuse a bipolar lead with two conductors, other embodiments use multipleconductors (e.g., if multiple different stimulations are delivered usinga single lead. Optionally or alternatively, non-electrical lead designsmay be provided as well. For example, for a thermal stimulator, twoconductors may be used to deliver electrical energy to a thermaltransducer. For chemical stimulation, a single lumen may be used todeliver a stimulating chemical. A second lumen may be used for washingand/or for suction.

FIG. 25A is a perspective cross-sectional view and FIG. 25B across-sectional view of a section of a lead 134. Such a lead may beused, for example, for substantially any of the embodiments describedherein.

In an exemplary embodiment of the invention, electrode lead 134 is inthe form of a tube (e.g., with a circular, or other cross-section,including optionally a concave cross-sectional portion) with two or moreconcentric layers. In an exemplary embodiment of the invention, lead 134comprises an external layer 130 optionally made of a flexible isolatingbio-compatible material, for example silicone. Optionally lead 134comprises a coil 133, which can, for example, provide structuralproperties to the lead and/or serve as a conduction path. Optionally,coil 133 is a spring. Other designs, such as one or more elongateribbons, a spiral or a hypotube, may be used as well.

In an exemplary embodiment of the invention, lead 134 comprises a layer131 made of a flexible isolating material, for example silicone. Inalternative embodiments, at least part of layer 131 is hollow, or isentirely absent.

A second conductor 132, optionally in the form of a coil spring, braidor wire is optionally provided within layer 131. In an exemplaryembodiment of the invention, conductor 132 is an anode and coil 133 isan anode. Optionally, component 132 is not a conductor and only providesstructural properties and/or a lumen. Conductor 132 is optionally filledwith an isolating layer. In some embodiments of the invention, the leadis made soft and hollow. This may allow the lead to not interfere withmovement of body parts and/or urine flow.

In an exemplary embodiment of the invention, a lead as described hereinhas a length of between 1 and 50 cm, for example, 10-20 cm and diameterof between 0.1 and 5 mm, for example, 3 mm. Optionally, the lead iselastic, for example, having a bending radius of less than 7 cm, 5 cm or2 cm and/or having an elongation of over 10%.

Intra Luminal Stimulators

A potential advantage of the urinary system is that, being hollow inparts, stimulators can be implanted within the system (e.g., withinureter, urethra, bladder, kidney and/or blood vessels). Such implantingmay reduce interference with external tissues and/or may assist instimulator placement and/or fixation. In an exemplary embodiment of theinvention, intra-luminal electrodes are more resistant to migrationbecause, for example, they contact only one tissue type and/or are heldin place by the structure of the lumen. In an exemplary embodiment ofthe invention, while part of the stimulator and/or the stimulatingcontacts thereof are intraluminal, the rest of the stimulator may lieoutside the lumen. This may further assist in anchoring.

FIG. 26 shows an intraluminal stimulator 124 (which may also be used forextra-luminal stimulation, for example, for stimulating a bladder), inaccordance with an exemplary embodiment of the invention. In the exampleshown, stimulator 124 includes a lead body 123, with a connector 127 atone end and electrode contacts at a distal end 122. Optionally,connector 127 includes a cathode connector 126 and an anode connector125, but it is noted that AC stimulation may be applied as well and/or alead may be used to deliver different stimulation levels to 2 or moreelectrode.

In an exemplary embodiment of the invention, at distal end 122, anelectrical connector 121 extends and a ring electrode contact 120 isprovided. Optionally, the two electrical contacts are separated by alayer of isolating material. Optionally or alternatively, otherelectrode contact designs, for example, as described below, are used.Optionally or alternatively, distal end 122 includes a screw forthreaded engaging of muscle tissue.

FIG. 27A shows a stimulator 314 having a body 302, optionally includinga pigtail or other anchoring mechanism at either end, in accordance withan exemplary embodiment of the invention. Stimulator 314 optionallycomprises at least one or more conducting surfaces, for example, 1, 2,3, 4 or more as shown 304, 305, 306, 307. These conducting surfaces canbe shorted together or not, depending on the embodiment, and may beconnected, for example, to an anode or to a cathode. Optionally at leastone of the conducting surfaces 304, 305, 306, 307 is connected to anisolated conducting medium 311 (e.g., a wire or wire pair) thatoptionally exits the body through the urethra and is optionallyconnected to a stimulator 415 such as described in FIG. 7.Alternatively, a stimulator controller is designed to reside in the bodyand/or in the bladder. In other embodiments, power is transmitted usingwireless means.

According to one embodiment stimulator 314 has at least one hollow lumen308 and optionally one, two, or more pores 310 along its length and/oron distal and/or proximal ends thereof. In some embodiments of theinvention, the pores may be used to allow fluid, optionally urine,optionally chemical substance, optionally a drug, to flow throughstimulator 314, optionally to a target.

In an exemplary embodiment of the invention, the distal and/or theproximal ends 312 and 313 of stimulator 314 are curved, for example,pre-formed to naturally have a pigtail configuration, which may be usedfor anchoring in the kidney pelvis and/or bladder.

FIG. 27B shows stimulator body 302 lying within a ureter 303 andanchored in a kidney 300 and bladder 311, in accordance with anexemplary embodiment of the invention.

FIG. 27C shows an alternative implantation method in which body 302extends out of the human body, for example, out through a urethra 315 orout through the pubic area.

FIGS. 28A-C3 illustrate designs for a stimulator including contactsand/or anchoring in the kidney pelvis in accordance with exemplaryembodiments of the invention.

FIG. 28A shows a stimulator 320 lying in a ureter 324 and optionallyincluding a plurality of contacts 322 in a kidney pelvis 321, inaccordance with an exemplary embodiment of the invention. In anexemplary embodiment of the invention, stimulator 320 includes a body inthe form of a thin and/or flexible wire 323, attached to a basketstructure including optional contacts 322. Optionally or alternatively,the basket structure is mounted on a ureteral tube and/or replaces oneof the pigtails of FIGS. 27A-C.

Optionally, contacts 322 include one or more cathodes and/or one or moreanodes. Optionally, the field (e.g., voltage potential difference) isapplied perpendicular to the ureter axis. In this and/or otherembodiments, field application direction can be, for example, along theureter (or other body part) axis, at an angle thereto and/orperpendicular thereto. Optionally, the field is applied between theinside and the outside of the ureter (e.g., using an external groundingelectrode).

Optionally, stimulator 320 or the basket portion thereof is elastic (orsuper-elastic) and is formed, for example, of an expanding wire mesh.Alternatively, the basket may be balloon expandable or expanded bymechanical distortion or by shape-memory distortion.

FIGS. 28B1-28B3 illustrate a method of implanting stimulator 320, inaccordance with an exemplary embodiment of the invention. A sheath 325having a basket in a closed state 326 is advanced along a ureter 324 toa kidney pelvis 321 (FIG. 28B1). Sheath 325 is slightly retracted sothat contacts 322 spread out (FIG. 28B2). Finally, sheath 325 iscompletely retracted leaving contacts 322 in contact with kidney pelvis321 and/or anchoring therein by interference, at least againstretraction (FIG. 28B3).

FIG. 28C1-28C3 illustrate alternative embodiments of a basket, forexample, a basket formed of axial and trans-axial lines 327 (FIG. 28C1),a helical coil 328 widening towards the kidney pelvis (FIG. 28C2), and aplurality of (radially and optionally axially) extending arms 329 (FIG.28C3).

FIG. 29A illustrates an intra-luminal stimulator 340 with medialelectrical contacts 341, according to an exemplary embodiment of theinvention. FIGS. 29B-29D2 illustrates medial contact designs suitable,for example, for contacts 341, in accordance with an exemplaryembodiment of the invention.

Optionally, but not necessarily, stimulator 340 is an inter-ureteralstimulator including (e.g., as in some previous embodiments) a body witha lumen 345, a plurality of pores 344 and/or pigtails at ends 342 and343 thereof. One or more wires 346 and/or the stimulator body may extendout of the urethra.

In an exemplary embodiment of the invention, stimulator 340 includesradially extending contacts 341, with an optional deployment mechanism347. Optionally, additional contacts, such as any of the designs shownherein are provided. Optionally, contacts 341 extend radially to adiameter which is about 110%, 150%, 200%, 300% or smaller orintermediate or larger percentages of a diameter of the body ofstimulator 340. This may cause slight distension of the ureter.

While a deployment mechanism 347 is shown, in some embodiments, there isno such mechanism and contacts 341 self extend when released by aconstraining outer tube which may then be removed from the body.Optionally, mechanism 347 is a tube which can slide to cover and/oruncover contacts 341 and radially compress them.

In an exemplary embodiment of the invention, contacts 341 are or aremounted on elastic elongate elements. Such contacts may all have a samepolarity or a voltage may be developed between them. Optionally oralternatively, two or more contacts may be provided axially displaced.In an exemplary embodiment of the invention, contacts 341 comprise 1, 2,3, 4, 5, or more circumferentially displaced contacts.

FIG. 29B1-29B2 show how radially extendable contacts may be deployed ina ureter, in accordance with an exemplary embodiment of the invention.As shown a plurality of contacts 350 are radially constrained by asleeve 348 (FIG. 29B1). When the sleeve is retracted (FIG. 29B2), forexample, removed from the body, electrode contacts 350 radially extendand ensure contact with the ureter (e.g., inner walls 353 thereof)and/or provide anchoring. Optionally, the electrodes are unsmoothedand/or include small barbs to engage the ureter wall. Optionally, duringinsertion, contrast medium is injected, for example through thestimulator lumen, to ensure that the contacts do not interfere with aureteral valve.

FIG. 29C1-29C2 show an embodiment of electrode contacts 350, where eachcontact is mounted at the tip of an extending arm.

FIG. 29D1-29D2 show an embodiment of electrode contacts 350, where eachcontact is mounted at the medial portion of a bent arm. This design maybe less likely to cause perforation of the ureter, than the design ofFIG. 29C1-29C2, but may be less well anchored.

FIGS. 30A-30D2 show exemplary intra-luminal stimulators 360 having athin body, in accordance with an exemplary embodiment of the invention.One potential advantage of having a thin body is reduced interactionand/or interference with body structures such as the ureter and/orvalves, allowing the UVJ to close, avoiding interference with kidneystones and/or ease of insertion using an enclosing catheter (e.g.,smaller diameter). For example, the diameter of stimulator 360 may be,for example, less than 1 mm, less than 0.4 mm, less than 0.2 mm orintermediate diameters.

Referring to FIG. 30A, stimulator 360 optionally has a pigtail or otherspace filling structure at one end 361 and/or another end 362 thereof.One or more wires 363 optionally extend out of the body. An expansiblemedial stimulation area includes a plurality of contacts 364 which canbe, for example, of any of the designs described herein. FIGS. 30A-20B2illustrate contacts at the ends of extending arms. FIGS. 30B1 shows howsuch arms are temporarily prevented from extension (FIG. 30B2) andmaintained in a closed configuration 366 by an overtube 367. FIG. 30C1shows how arms amounted on arcs 368 are temporarily prevented fromextension (FIG. 30C2) by a slidable overtube 367.

Optionally, deployment, in this or other embodiments, is by adhering thecontacts to the body of stimulator 360 optionally using a material thatdissolves in the body, softens at body heat, is made to release the armsby the provision of a chemical or otherwise releases the contacts oncein the body.

FIG. 30D1 shows an electrical contact design having a spiral electrode370 twisted around stimulator 360 and/or mounted as an undulating ribbonthereon. FIG. 30D2 shows an alternative embodiment having contacts 371in the form of elongate contact regions.

Optionally, such regions are, for example, about 1 mm, about 2 mm, about3 mm, about 8 mm or smaller or intermediate or greater in length.

FIG. 31A-E show intra-luminal stimulators 460 having balloon-expandableelectrical contacts, in accordance with exemplary embodiments of theinvention.

Stimulator 460 may be similar to any of the designs shown above, thedifferences being an inflatable element 470, such as a balloon with oneor more contacts 461 mounted thereon or therewith. Optionally, anoptional port 469 for an inflation lumen 465 is provided for inflationof balloon 470. As in some of the designs above, stimulator 460 can havea body with a lumen 465 and optional pigtails 463 and 462 at endsthereof. Optionally, one or more wires 474 extend from the body.Optionally or alternatively, inflation lumen 466 does not fill lumen 465of stimulator 460. Optionally, lumen 465 includes one or more pores 464which may be used for passage of fluid such as urine.

FIGS. 31B1-31B2 show stimulator 460 in a ureter 467, with (FIG. 31B2)and without (FIG. 31B1) inflation of balloon 470. As can be seeninflation may cause distension of the ureter. In some embodiments, suchinflation is used without electrical (or chemical or other) stimulationor in addition to it. Optionally, lumen 466 serves as a conduit foracoustic or mechanical vibration from outside the ureter (e.g., outsidethe body) to the ureter. A mechanical transducer may be placed, forexample, in contact with port 469 outside the body.

FIG. 31C1-31C2 show cross-sectional views of FIG. 31B1 and FIG. 31B2.Optionally, balloon 470 is not inflated enough to collapse lumen 465.Optionally, lumen 465 is stiffened thereat, for example, by thickeningor by a layer of stiffer material. Optionally or alternatively, balloon470 defines channels for urine flow along it or through it.

FIG. 31D1-31D2 shows two exemplary alternative electrode contactdesigns. In configuration 471 (FIG. 31D1), bands of electrodes (ormeshes) lie transverse to the axis of stimulator 460, and are optionallyseparately electrified and/or act as a bipolar electrode. In design 473(FIG. 31D2), a single mesh is provided.

FIG. 31E is a cross-sectional view of a design for a stimulator 460,showing a lumen 475 for fluid (e.g., urine) and one or more lumens for aconductor 476 and optional inflation lumen 466.

In some embodiments, the contacts 461 are configured to compressradially and inflation is used to maintain them radially distended.

In some embodiments, balloon 470 is deflated once contacts 461 areextended and engage ureter walls and/or are plastically deformed bydistention. Optionally, contacts 461 and wires 474 are left in the bodyand the rest of the delivery system (e.g., balloon 470, inflation lumen466) are removed. This may be similar to the implantation of a stent,where contacts 461 may be formed in a cylindrical, stent-like,configuration.

In some embodiments of the invention, anchoring of any of the abovedesigns is temporary and, for example, a stiffening element dissolves orotherwise decomposes after a time and then the stimulator is unanchoredand falls out.

While the above (and below) embodiments focus on electrical stimulation,they may also be used for non-electrical stimulation in conjunction withor instead of electrical stimulation, by replacing an electrical contactwith a suitable transducer. For example, a transducer can be apiezoelectric element, a light emitting element, an inflatable element,a chemical eluting element, an iontophoretic element and/or othertransducers, for example, as known in the art. Optionally, the abovedescribed wires are replaced by tubes or wires or fibers, as required.

Optionally or alternatively, to the contacts being stimulators, thecontacts may be used for sensing and/or may be replaced by a suitabletransducer. The various structures described herein may be useful forensuring uniform contact between the sensor transducer and the bodystructure being sensed.

It should be noted that while many of the described-herein electrodecontact configurations appear rotationally symmetric, this need not bethe case in all embodiments. For example, contacts may be provided inonly some sectors of the contact configuration. Optionally oralternatively, stimulation is different at different sectors.Optionally, the level of stimulation for each sector (e.g., efficacyand/or pain considerations) and/or which sector to stimulate, areselected during a configuration stage and/or based on desired therapy.Optionally, the stimulator is designed to avoid rotation in situ.

Extra-Luminal Stimulators

In an exemplary embodiment of the invention, a stimulator is mountedoutside of a lumen, or on a tubular structure, such as a nerve or ureteror a different structure, such as a kidney or bladder. As shown below,some designs of mounting methods allow the stimulator to move with thestructure on which it is mounted and/or otherwise not interfere with itsfunction.

FIGS. 32A-C show an extra-luminal stimulator 163, for example, anelectrode, mounted on a lumen, for example a ureter 166, in accordancewith an exemplary embodiment of the invention.

Referring first to FIG. 32A, which shows stimulator 163 with a sectionmissing (e.g., the section which completes to a cylindrical shape),stimulator 163 can include one or more contacts 162, 169. In anexemplary embodiment of the invention, at least one contact iscircumferentially arranged. Optionally or alternatively, at least onecontact is axially arranged. Other arrangements, such as spiral or pointcontacts may be used as well.

In the embodiment shown, a cylindrical body 161, optionally electricallyinsulating, has one or more contacts 162, 169 formed thereon andelectrically coupled, e.g., via couplers 164, 165 to a lead 168.Optionally, body 161 is axially split and is lockable, for example,using a latch mechanism formed of a buckle 160 and a connector 167 (FIG.32C). Other fastening mechanism can be used as well, for example a pinon one side that fits into a recess on the other or otherinterference-fit. Optionally or alternatively, body 161 is plasticallydeformable. Alternatively, body 161 is elastically pre-configured toretain a cylindrical shape. In some embodiments, a fastening mechanism,if any, is used to prevent inadvertent removal from the structure onwhich the stimulator is mounted, rather than regularly resist removalforces.

In an exemplary embodiment of the invention, body 161 is formed ofsilicone. Optionally or alternatively, one or more conducting componentsof stimulator 163 are formed of a conductive silicone.

FIG. 32B shows body 161 mounted on a ureter or other tubular structure166.

FIG. 32C shows stimulator 163 mounted on a ureter or other tubularstructure 166, with no parts hidden. Optionally, such contacts areextension of contacts 162 and/or 169 and/or are separate or additionalcontacts.

Optionally, buckle 160 (or other connector design) or connector 167 isused to attach to other body structures or to the tubular structure, forexample, by suturing.

Optionally or alternatively, buckle 160 and/or connector 167 is replacedby or enhanced by one or more hooks or barbs positioned to engage thetubular structure or other nearby tissues.

FIG. 33A shows a stimulator 143 including a lead body 144 and one ormore patch contacts 146, 147, which may be, for example, electricalcontacts or other stimulation transducers. In an exemplary embodiment ofthe invention, lead body 144 is terminated at one end by a connector142, having (for DC stimulations) an anodal contact 141 and a cathodalcontact 140. Optionally, connector 142 is designed for connection to animplantable controller.

In an exemplary embodiment of the invention, lead body 145 terminates atan opposite end with a coupler 145 which extends electrical wiring outof lead body 144, for example into separate wires for each electrodecontact 146, 147. In some embodiments of the invention, distal end 145acts as an electrical contact of one polarity while contacts 146, 147have a different polarity. Optionally or alternatively, each contact146, 147 (or more) can be controlled to have a different electricalpotential.

In an exemplary embodiment of the invention, a contact 146 has the shapeof a circle or an ellipse. Optionally, not shown, electrode contact 146includes an attachment mechanism, for example, a clip or suture holder,for example, a clip or a hole for attaching a suture and fixating totissue. Optionally or alternatively, the contact is coated with anadhesive layer.

FIG. 33B illustrates an exemplary alternative extraluminal stimulatordesign 153, which can be the same as that of FIG. 33A, except that acuff 155 (and/or 156) is provided instead of a patch electrical contact146, 147.

As shown in a blow-up FIG. 33C, a cuff 155 can include, for example, asplit annular or ellipsoid shape 157, optionally of conducting materialor including inside and/or outside a conductive material. Optionally,split shape 157 is urged shut by an elastic element (e.g., a springloaded hinge 158) or by the elasticity of shape 157. Optionally, a cable159 electrically connects cuff 155 to a lead body 154. Alternatively,cuff 157 is a curled elastic extension of cable 159.

FIG. 34A-B illustrates an extraluminal electrode adapted to conform to ashape and/or dynamics of an underlying structure such as a ureter, inaccordance with an exemplary embodiment of the invention. In anexemplary embodiment of the invention, the electrode has a body 442 andone or more contacts 444, separated by a compressible layer 443. In use,when the underlying structure expands (FIG. 34B), compressible layer 443is compressed, and when the underlying structure contracts, layer 443expands. Optionally or alternatively, layer 443 ensures contact betweencontacts 444 and the underlying body structure.

In an exemplary embodiment of the invention, layer 443 comprises ahollow element filled with a fluid, for example saline (in which casecompression may entail expansion in a different part thereof) or air orother compressible gas. In an alternative embodiment, layer 443 isformed of a sponge or a soft silicone, optionally within a flexible orelastic capsule. In an exemplary embodiment of the invention, layer 443is selected to resist dynamic movement of the underlying structure to anextent of less than 50% (or less than 40%, 30%, 20% or intermediatepercentages) of a radial force applied by the structure. In someembodiments, layer 443 is provided only underlying contacts 444 and/orotherwise incompletely encircles and/or covers the inside of body 442.

In an exemplary embodiment of the invention, body 442 is elastic,allowing it to conform to changes in diameter of underlying structures.Optionally, the body 442 can be inflated or deflated, or filler withsoft medium, in order to allow tight contact with underlying structurewithout applying pressure on that structure, for example ureter 441. Inan exemplary embodiment of the invention, body 442 is selected to have aminimum diameter at which it does not apply pressure on the underlyingstructure.

In an exemplary embodiment of the invention, body 442 is soft, forexample, made of silicone. Optionally or alternatively, body 442 isisolating. Optionally, layer 443 serves to seal the edges of body 442 sothat electrical fields (e.g., is dielectric and/or isolating) and/orchemicals provided by contacts 444 does not exit between the structurebody 442 to the nearby tissues.

In an exemplary embodiment of the invention, layer 443 is inflatable andits inflation amount and/or stiffness are controlled using a fluidchannel 445 connected to a valve and/or port 446, through whichinflation fluid may be added and/or removed.

In the example shown, the amount of material and/or softness of layer443 and the diameter of body 442 is selected so as to allow contact ofthe conductive surface 444 with ureteral wall 440 during ureteral bolus447. Optionally, contacts 444 are flexible and soft or may be, forexample, small rigid elements.

In an exemplary embodiment of the invention, an extraluminal electrodecontact has a body length of, for example, 2-4 cm and/or an electricalcontact area of, for example, 0.5-5 cm². Optionally or alternatively,such an electrode has an inner diameter of, for example, 4-6 mm.

In an exemplary embodiment of the invention, kinking of the ureter (orother elongate structure) by the cuff is prevented by preventingtwisting of the cuff around an axis transverse to the ureter axis.Optionally, such twisting is prevented by mounting on the cuff andelongate element, not attached to any tissue, which is substantiallyparallel to the ureter axis. Optionally or alternatively, to an elongateelement, a mesh is attached. Such a mesh and/or elongate element maymechanically lodge in tissue and/or adhere thereto, and thereby preventsubstantial twisting of the cuff. Such a design may also be useful toprevent migration.

Hybrid Stimulator

In some embodiments of the invention, a stimulator includes bothintraluminal stimulation and/or sensing components and extraluminalstimulation and/or sensing components.

FIG. 35 shows a hybrid stimulator including both intra- andextra-luminal components, in accordance with an exemplary embodiment ofthe invention. In the example shown, the components are electricalcontacts. In other embodiments, one or more of the components is anon-electrical stimulating transducer and/or a sensor.

In an exemplary embodiment of the invention, the hybrid stimulatorincludes one or more external contacts 405 and 406 mounted on a lumen(e.g., a ureter), for example, using any of the methods describe herein,and an internal contact 407, mounted inside the lumen. Optionally,contact 407 is located proximal, distal, between or directly across theextra-luminal contacts 405, 406. Optionally, more than one contact 407is provided.

In an alternative embodiment, component 407 is non electrical and is,for example, a piezoelectric pressure sensor or a source of ionicmaterial for delivery into the ureter.

Contacts 405 and 406 are optionally isolated from the rest of the bodyby an isolating layer 402, optionally including a grounded conductinglayer (not shown) within. Conductors 405 and 406 are coupled to one ormore conducting lines 403 (optionally isolated from the body), by, forexample, connectors or welding points 404.

Exemplary Wireless Stimulation

In some embodiments of the invention a stimulator is implanted in thebody and power is provided from outside. Optionally, also control isprovided from outside. Optionally, such control is provided by usingpower from outside to directly activate the stimulator and variousstimulation sequences are provided by varying the power provision. Sucha stimulator can be any of the stimulator types described herein, forany of the targets. Optionally or alternatively, power is stored locallyfor a short while before being used, for example, in an inductor or acapacitor. Optionally or alternatively, power is used to release astimulant, such as a chemical and/or heat a thermal stimulator.

FIGS. 36A-E illustrate a ureter-based wireless stimulator 480, inaccordance with an exemplary embodiment of the invention. In the exampleshown, two spaced apart electrode contacts 481 are interconnected by acoil 482, optionally isolated. The circuit can be closed, for example,by the human body or urine. Optionally, the coil receives power fromoutside the body for example, by RF induction or low frequency coupling.Other power antenna designs may be used, for example, patch antenna.Optionally, additional power circuitry is provided, such as a capacitorfor storing power and/or pulse shaping elements.

Additional illustrated optional elements of stimulator 480 are a hollowlumen, one, two or more pores 489 that link the lumen to the outside ofstimulator 480 (e.g., along its length and/or at one or both endsthereof) and optional pigtail coils for anchoring at one or both ends ofstimulator 480. Such a lumen may be used, for example, to allow fluid,for example urine, or a chemical substance, optionally a drug to flowthrough electrode 480, optionally to a target.

In an exemplary embodiment of the invention, during implantation,stimulator 480 is inserted into the (or two are inserted, into both)ureteral lumen until a desired location thereof is reached. In oneexample, at the desired position, the distal curved parts of theelectrode are optionally located in the renal pelvis and in the bladder.

In an exemplary embodiment of the invention, power is transmitted tostimulator 480 by electrifying one or more coils outside the body. FIG.36B1-36B2 show two examples of extracorporeal power transmitters 486including coils 485 and/or coils 487. Optionally, as shown, such adevice is made into a vest or belt 488 worn on the body (see FIG. 36C),with spaced apart stimulators, that transmit power to an indwellingstimulator, having a cross-section shown as 483.

FIGS. 36D and 36E shows an embodiment where a coil(s) 484 surround abody (FIG. 36E), with an optional isolating material 486 providedbetween coil 484 and the body.

In an exemplary embodiment of the invention, the orientation of thepower transmitting coils is selected according to the design andimplantation orientation of the stimulator. Optionally or alternatively,the stimulator and/or power transmitter include multiple orthogonaltransmitting elements to ensure power delivery and reception at a rangeof or at all orientations.

Exemplary Nephrostomy Based Stimulation

While one route to internal urinary system lumens is via the urethra, insome embodiments of the invention, the kidney, internal kidneystructures and/or urinary system lumens are accessed via a nephrostomicapproach, or by a reverse nephrostomic approach.

A potential advantage of a nephrostomy approach is that there is nointerference with the lower urinary tract and that the groin area, whichis anatomically complex, may be avoided.

FIG. 37 shows an exemplary nephrostomic stimulation device, according toan exemplary embodiment of the invention, optionally including anexternal control box 1111, optionally a pulse generator. In someembodiments, control box 1111 is miniaturized and/or implanted under theskin. Optionally, in this and/or other embodiments, a control box mayinclude circuitry and/or chemicals for stimulation and/or otherstimulation sources.

In an exemplary embodiment of the invention, a stimulator 1105 isinserted through the skin, following a nephrostomy route 1106,optionally through a parenchyma of a kidney 1108 optionally to the renalpelvis 1109, optionally until the ureter 1102, optionally down to abladder 1201 (see FIG. 39). Stimulator 1105 may be attached to (or runalong) a skin at a section 1104 thereof and include an optional plug1110 for attachment to control box 1111.

In an exemplary embodiment of the invention, stimulator 1105 includes atleast one conductive surface 1103 (e.g., for an electrical stimulator;other stimulators would use other transducers). Optionally section 1104includes a conducting portion in contact with skin 1100. Conductivesurface (or portion) 1103 can be in various locations, for example, oneor more of in contact with the pelvic wall and in contact with theureter 1102. Different conductive portions are optionally configured tobe separately activated.

FIG. 38 shows an embodiment where a stimulator 1105 is configured tovolumetrically expand in kidney pelvis 1109, optionally providing one ormore of anchoring, ensuring contact with lumen walls and multiple pointsof stimulation. In the embodiment shown, conducting surface(s) 1103, ofwhich there may be, for example, 1, 2, 3 or more, are connected by aconducting element (e.g., a wire braid or ribbon) to connector 1110,optionally located outside the body. Optionally, the stimulation device1105 has at least one hollow lumen, optionally with one or more holes1202 that provide access to the lumen. Optionally the hollow lumen 1401is connected to a valve 1203, optionally located outside the body. Suchvalve may be used, for example, to withdraw samples or to inject achemical to stimulate the ureter. Optionally the stimulation device 1105can be fixated on the skin by a connector 1204.

FIG. 39 shows an exemplary stimulator 1105 inserted in a kidney pelvis,ureter and bladder, in accordance with an exemplary embodiment of theinvention. In the embodiment shown, a plurality of conducting portions1103 are positioned to lie along the ureter, and a pig-tail portion 1301coils in the bladder, optionally providing for trigone stimulation(e.g., with a conductor, not shown) or for bladder stimulation (e.g.,with one or more conductors not shown) and/or for anchoring.

FIGS. 40A1-40A3 show a detailed view of stimulator 1105, in two variantsthereof and in an optional relaxed state, in accordance with exemplaryembodiments of the invention. FIGS. 40B1-40B3 show cross-sections ofstimulator 1105, illustrating layouts of conductors in accordance withsome embodiments of the invention.

FIG. 40A1 and FIG. 40A2 show two exemplary stimulators, one (FIG. 40A1)with a lumen along its entire length and conductors on its outside andanother (FIG. 40A2) with one or more conductive elongate elementsextending past its end (and/or an end of a lumen thereof).

FIG. 40B1-40B3 show three exemplary cross-sections of a stimulator 1105.A first cross-section (FIG. 40B1) shows two lumens, 1401 which accessesoptional holes 1202 and 1404, optionally filled with a conductivematerial and/or used to elute chemical stimulants. Optionally, lumen1401 is used to carry a stylet which can be used to stiffen stimulator1105 and/or navigate it and/or assist in penetrating tissues, duringinsertion. After insertion such a stylet may be removed.

A second cross-section (FIG. 40B2) shows a plurality of conductive wires1402 lying within a wall 1403 of the stimulator, and not in contact withlumen 1401 or the urinary system (e.g., except at conductors 1103).

A third cross-section (FIG. 40B3) shows a plurality of conductive wires,optionally coated, which lie along the outside of wall 1403.

FIGS. 41A-B shows two exemplary layouts of stimulators 1501 lying in aurinary system, in accordance with exemplary embodiments of theinvention. In the example shown, a stimulator 1501 is optionally thin,for example, less than 1 mm in diameter and/or is soft enough to notinterfere with valves in the ureter. In an exemplary embodiment of theinvention, stimulator 1501, when released achieves the shapes shown inthe figure—curling up in kidney pelvis (FIG. 41B) or bladder (FIG. 41A).Optionally, stimulator 1501 is inserted with a more rigid over tubewhich prevents premature reforming thereof.

FIGS. 41C1-41C3 shows three exemplary designs for stimulator 1501 or1105.

In FIG. 41C1 the entire outside of the stimulator is conductive, atleast for an axial length of 200 mm and/or for a complete circumferenceor an arc angle of 90 degrees.

In FIG. 41C2, an axial portion of the stimulator is covered by anisolating material 1502. In FIG. 41C3, an isolating axial element isperiodically covered with a conductive material (or such a contact isattached onto the axial element and/or a conductor in the element isexposed.

FIG. 42A shows an alternative design for a stimulator 1105, in which apelvic anchoring element 1601 is provided. In an exemplary embodiment ofthe invention, the anchoring element is selectively relaxable, to allowfor removal of stimulator 1105 from the body.

FIGS. 42B1-42B2 show a self expanding element 1602 including one or morearms 1602 a and an elastic element 1602 b which spreads the arm(s) awayfrom stimulator 1105. When a pull wire 1604 is pulled, arms 1602 a areretracted towards the body of stimulator 1105. In an alternative design,the arms are normally closed and pulling on the string spreads them out.Other expanding anchor designs, for example those known in the art ofbladder anchoring, may be used.

FIGS. 42C1-42C2 show a balloon-based anchoring, in which an inflatableelement 1605 is optionally inflated (FIG. 42C1) or deflated (FIG. 42C2)to a state 1606, to control anchoring. Optionally, inflatable element1605 is connected by a lumen 1609 to outside the body, were, forexample, a valve and/or port 1608 are used to introduce or removeinflation fluid and/or measure inflation pressure and/or where anoptional finger pump and/or fluid reservoir 1607 may be provided.

While a regular nephrostomic approach has been described, in someembodiments of the invention, a reverse nephrostomic approach isprovided, in which a catheter or guiding element is pushed up the ureterand then out of the kidney to outside the body. Then the catheter may beretracted carrying a stimulator along with it from outside the body.Such reverse insertion may be useful, for example, in patients whereaiming (e.g., using ultrasound) is not sufficient for correct placementof the stimulator in the ureter, or for patients where advancing of acatheter in the ureter is difficult or may cause damage, while reverseadvancement may be easier.

Exemplary External Stimulation

In some embodiments of the invention, stimulation of the urinary systemis provided non-invasively, using energy provided from outside the body.

FIG. 43 illustrates an exemplary transcutaneous stimulation system, inaccordance with an exemplary embodiment of the invention. In oneexample, the stimulation system uses electrical stimulation. As shown,one or more pairs of electrodes 200 and, optionally, 201 are used tocreate an electrical potential inside the body. Optionally, a singleelectrode includes both anodal and cathode contacts. Other electrodearrangements may be provided as well, for example, electrodes 200 beinganodes and electrodes 200 being cathodes or vice versa.

A control circuit 203 optionally includes a user input and/or othercontrol methods and mechanisms (e.g., including sensor input) asdescribed above. Optionally, circuit 203 is connected to electrodes 200and/or 201 by leads 202. Optionally or alternatively, the connection iswireless.

In an exemplary embodiment of the invention, the electrodes areconfigured to stimulate one or more targets in the urinary system asdescribed above (e.g., kidney, ureters, trigone) and/or nervous tissuerelated to the urinary system.

In an exemplary embodiment of the invention, stimulation other thanelectrical stimulation is used. In one example, magnetic stimulation ofeddy currents may be provided (e.g., and electrodes 200 and/or 201 bereplaced by a suitable transducer). In another example, acoustic (e.g.,ultrasonic) stimulation is provided and electrodes 200 and/or 201replaced by acoustic transducers. Optionally, such transducers are usedfor imaging and/or other detecting of target structures. For example,the bladder may be located based on its unique reflection profile. Thismay assist in manual or automatic aiming of acoustic beams at thetrigone and/or ensuring stimulation is aimed at correct place.

In some embodiments of the invention, during a setup phase, thepatient's internal body structures are imaged, for example, usingultrasonic imaging, in order to help adjust the stimulation. Optionallyor alternatively, stimulation is adjusted until a desired effect on thepatient is achieved.

Exemplary Kidney Surface Stimulation

In some embodiments of the invention, the surface of a kidney and/or itsinterior are stimulated form the kidney surface, optionally in additionto stimulation of other parts of the urinary system, in accordance withan exemplary embodiment of the invention.

FIG. 44A shows a stimulator 382 (e.g., an electrical stimulator with aconducting inner surface) mounted on a kidney 380 and, optionally, alsoincluding a section 383 mounted on a ureter 381. In some embodiments,only one of 382 and 383 is stimulating and the other serves foranchoring. In other embodiments, each has a different electricalpotential (e.g., with 382 being an anode or a cathode). As shown,section 383 is optionally slidably mounted on ureter 381. Optionally oralternatively, stimulators are attached using adhesive, clips and/orsutures. Optionally, stimulator 382 includes a plurality of contacts soas to cause electrical potential changes inside the kidney, rather thanonly at its surface. Optionally, the inner surface of stimulator 382comprises an array of electrical (or other) stimulators.

Stimulator 382 (and section 383) can be connected to substantially anystimulator control mechanism described herein. Optionally, stimulator382 and/or section 383 include a sensor, for example, a ureter impedancesensor, ureter peristalsis sensor and/or ureteral flow sensor.

FIG. 44B shows an alternative design for a kidney stimulator, includinga patch or a sleeve 384, including (the figure showing the inner layer),a kidney stimulator patch section 385 and a ureter patch section 386.Optionally, the patch sections are chemical elution sections, forexample, controlled by electrical field from a stimulator control, todeliver chemicals by, for example, iontophoresis.

In an exemplary embodiment of the invention, patch 384 is non conductingsheet and is optionally composed of a soft material, optionally insertedposterior to the kidney 380.

Combination Stimulators

The above has described many types of stimulators. It should be notedthat a stimulation system may include multiple of the above stimulatortypes in a same system. Further, in some cases, a single stimulator hasmultiple portions, for example, sequentially arranged, possibly spacedapart more than in the above hybrid stimulator, possibly directed atdifferent targets and/or different body portions. For example, a bladderstimulator can include an extension which acts as a ureter stimulator,following intra-luminal designs as shown herein, for example. In anotherexample, two ureters may be stimulated using two separate ureterstimulators. Optionally, the two stimulators share a singlecontrol/power cable exiting, for example, through the urethra.Optionally or alternatively, the two stimulators share a structuralcomponent that lies in the bladder, optionally for bladder and/ortrigone stimulation. Different parts may also have different stimulationmodalities (e.g., chemical, thermal, electrical).

Exemplary Specific Applications

The above has described many variants of devices and features which maybe used together. The following lists some particular collections offeatures and usages into exemplary devices, in accordance with someembodiments of the invention.

A bladder indwelling catheter. Optionally the placement is performed asshown in FIG. 9C. Optionally the device will be used on acutedecompensated heart failure patients admitted to the hospital. Thesepatients can benefit from short term enhancement of renal function andinterruption of acute cario-renal syndrome. Many of these patientsundergo insertion of a regular bladder catheter for urine measurement,so a new procedure is not needed. The stimulation will optionallycommence in the emergency department, and last as long as patient'sstatus, as determined from a number of parameters, including weight,dyspnea, cardiovascular and kidney functions, require it. Thestimulation will optionally be provided in short half an hour sessionsgiven every 4-8 hours or as determined by a feedback from sensors oroutside. One optional input may be blood pressure, for safety reasons(e.g., not to reduce or increase blood pressure inappropriately).Optionally, urine flow sensing can be provided from the device itself tocalibrate the amount of stimulation needed, as urine flow is an easy tomeasure marker of kidney function. Additional optional group of patientstreated by such device may include patients suffering from ahepato-renal syndrome. In this case, the stimulation may continuelonger, and may optionally serve as a bridge to keep the patient alivefor a liver transplant.

Insertion of an implantable device similar to FIG. 6 or FIG. 21.Patients that cannot undergo an operation for a lead/IPG placement, maybenefit for ureteral catheter insertion (FIG. 30), or nephrostomycatheter insertion (FIG. 37). The stimulation may optionally becommenced for half an hour 3-6 times a day, optionally when the patientis resting, or alternatively when the patient is active. Feedback tostimulation can be from an external device, optionally measuring weightor blood pressure of a patient. Optionally, stimulation is increasedwhen patient's weight or blood pressure increases. Patients that canbenefit from this device include CHF hypertension and CKD patients. InCHF patients, interruption of a chronic cardio-renal syndrome byreduction of the renal sympathetic drive may halt disease progressionand may lead to a decrease in a number of hospitalizations. Patientssuffering from hypertension, or chronic kidney disease may also benefitfrom a chronic device implantation, as the reno-renal reflex may bedysfunctional in these patients, leading to improper sodium handling andincrease blood pressure in these patients.

Optionally, a stimulation sequence for these patients may includesensing of urine flow or urine sodium concentration, performed every fewseconds, minutes or hours and providing a stimulation of a reno-renalreflex when urine flow or sodium concentration increase so as tooptionally substitute for a malfunctioning natural reno-renal reflex.

General

It is expected that during the life of a patent maturing from thisapplication many relevant tissue stimulators will be developed and thescope of the term stimulator is intended to include all such newtechnologies a priori.

As used herein the term “about” refers to ±10%.

The terms “comprises”, “comprising”, “includes”, “including”, “having”and their conjugates mean “including but not limited to”. This termencompasses the terms “consisting of” and “consisting essentially of”.

The phrase “consisting essentially of” means that the composition ormethod may include additional ingredients and/or steps, but only if theadditional ingredients and/or steps do not materially alter the basicand novel characteristics of the claimed composition or method.

As used herein, the singular form “a”, “an” and “the” include pluralreferences unless the context clearly dictates otherwise. For example,the term “a compound” or “at least one compound” may include a pluralityof compounds, including mixtures thereof.

The word “exemplary, instance or illustration”. Any embodiment describedas “exemplary” is not necessarily to be construed as preferred oradvantageous over other embodiments and/or to exclude the incorporationof features from other embodiments.

The word “optionally” is used herein to mean “is provided in someembodiments and not provided in other embodiments”. Any particularembodiment of the invention may include a plurality of “optional”features unless such features conflict.

Throughout this application, various embodiments of this invention maybe presented in a range format. It should be understood that thedescription in range format is merely for convenience and brevity andshould not be construed as an inflexible limitation on the scope of theinvention. Accordingly, the description of a range should be consideredto have specifically disclosed all the possible subranges as well asindividual numerical values within that range. For example, descriptionof a range such as from 1 to 6 should be considered to have specificallydisclosed subranges such as from 1 to 3, from 1 to 4, from 1 to 5, from2 to 4, from 2 to 6, from 3 to 6 etc., as well as individual numberswithin that range, for example, 1, 2, 3, 4, 5, and 6. This appliesregardless of the breadth of the range.

Whenever a numerical range is indicated herein, it is meant to includeany cited numeral (fractional or integral) within the indicated range.The phrases “ranging/ranges between” a first indicate number and asecond indicate number and “ranging/ranges from” a first indicate number“to” a second indicate number are used herein interchangeably and aremeant to include the first and second indicated numbers and all thefractional and integral numerals therebetween.

As used herein the term “method” refers to manners, means, techniquesand procedures for accomplishing a given task including, but not limitedto, those manners, means, techniques and procedures either known to, orreadily developed from known manners, means, techniques and proceduresby practitioners of the chemical, pharmacological, biological,biochemical and medical arts.

As used herein, the term “treating” includes abrogating, substantiallyinhibiting, slowing or reversing the progression of a condition,substantially ameliorating clinical or aesthetical symptoms of acondition or substantially preventing the appearance of clinical oraesthetical symptoms of a condition.

It is appreciated that certain features of the invention, which are, forclarity, described in the context of separate embodiments, may also beprovided in combination in a single embodiment. Conversely, variousfeatures of the invention, which are, for brevity, described in thecontext of a single embodiment, may also be provided separately or inany suitable subcombination or as suitable in any other describedembodiment of the invention. Certain features described in the contextof various embodiments are not to be considered essential features ofthose embodiments, unless the embodiment is inoperative without thoseelements.

Various embodiments and aspects of the present invention as delineatedhereinabove and as claimed in the claims section below find experimentalsupport in the following examples.

EXAMPLES

Reference is now made to the following examples, which together with theabove descriptions, illustrate some embodiments of the invention in anon limiting fashion.

Example I Experimental Setup

The experiments were performed on healthy SD rats that were anesthetizedwith Inactin. A stimulating electrode, made of two platinum plates (eachwith area of about 5 mm²) located 2-3 mm apart, was placed under one ofthe ureters. Typically the electrode was placed about 1 cm from thepelvis. The lower side of the electrode was isolated from the rat's bodyby a silicone coating. Both ureters were then catheterized and the urinecollected. Great care was given to preserve the temperature of theanimal and the hydration status; the left femoral vein was catheterizedand solution of saline with inulin and para-aminohippuric acid (PAH) wasperfused at a constant rate of 3 cc/h.

Following the procedure the animal was left undisturbed for one hour foran equilibration of the solutes. The experiment began with baselineurine collection, followed by a stimulation session and then by arecovery period. Each collection lasted 30 minutes. In some experimentswe abstained from inserting ureteral catheters, so that not to irritatethe ureter. Blood samples were taken once an hour.

The ureters were stimulated with trains of biphasic 1 ms long, 2-10Vpulses. The inter stimulus interval was 10 ms (train frequency of 100Hz). In about half of the experiments stimulation trains were deliveredfor 30 sec, once every minute. As the results of these experiments werenot different from continuous stimulation experiments they were pooledtogether in the statistical analysis.

Results

Following a stable baseline collection period, we stimulated the ureterby a bipolar electrode located about 1 cm from the pelvis.

FIG. 45 illustrates urine flow collections from a single animal from thestimulated kidney (left) and the contralateral kidney (middle) togetherwith total urine flow (right), show stable basal urine flow (two leftcolumns in each plot), that sharply increases during stimulation (grey)and remains elevated for at least half an hour thereafter in bothkidneys.

FIG. 46 illustrates GFR analysis from the same animal as above, showingincreased bilateral GFR during and following ureteral stimulation.

FIG. 47 illustrates RBF analysis from the same animal as above, showingincreased bilateral RBF during and following ureteral stimulation.

It should be noted that the results show, in general, that even after astimulation of a minute or two, a lasting effect of several minutes canbe detected.

The results also show a correlation between RBF, GFR and urine flow fromthe same animal. In general, all parameters showed a high degree ofcorrelation; indicating that the effects shown may be due to a singleintrinsic renal mechanism, such as the reno-renal reflex.

Stimulation of the ureters increased the total (bilateral) urine flow by25±22%, GFR by 26±30% and RBF by 13±21% (n=8 animals). The increase inurine flow was statistically significant (P=0.04; n=8).

FIG. 48 illustrates the ratio of change in bilateral urine flow, GFR andRBF during ureter stimulation in relation to control measurements (n=8).

There was some experimental failure in rats, probably due to therelative size of the rat and of the stimulators, so additionalexperiments were performed on sheep.

Modulation of Urine Flow on a Short Time Scale

For the experiments presented above, half-an-hour urine collections wereused. The long collection period was necessary for reliablemeasurements. In order to know the time scale of the effect ofelectrical stimulation of the ureter, we used a different approach toexplore the immediate effect of nerve stimulation. In this set ofexperiments we measured urine flow along a ureter-catheter on atimescale of minutes during control/stimulation settings.

FIGS. 49A-B illustrate two examples of single kidney urine flow, asmeasured in a ureter catheter. In the example of FIG. 49A, stimulationof the ureter for one minute sharply increased urine flow, the effectlasting after discontinuation of the stimulation. In the example of FIG.49B, ureteral stimulation transiently increased urine flow, without thelong term effect.

In these experiments we were able to see the effect of stimulation onurine flow, bolus sizes and bolus frequency.

We noticed that electrical stimulation often produced a rapid increasein the rate of urine flow, and in many cases the effect outlasted thestimulation period. Bolus size tended to increase during stimulation, insome instances the flow became continuous. These findings indicate thatstimulation may not be given continuously to achieve the desired effect.On one hand, this means that longer battery life can be maintained, onthe other hand intermittent stimulations may be better tolerated by thepatient.

The increase in urine flow had variable amplitude, possibly because ofnerve fatigue and activation of other feedback mechanisms that controlurine flow. In some embodiments of the invention, such effects are usedto control the main effect.

The Effect on Blood Pressure

In 4 animals stimulation of the ureter was coupled with mean arterialblood pressure measurements.

In all animals tested, the mean blood pressure sharply decreased at thebeginning of the stimulation by 7.4±3.6 mmHg, but after about 10 secondsstabilized at 2.7±1.5 mmHg below the original mean arterial pressure(not statistically significant; P=0.23) and was stable during the fullcourse of the stimulation.

FIG. 50 illustrates an example measurement of mean arterial pressure(MAP) during electrical stimulation of the ureter. After an initial dropthe MAP stabilizes to near the control values.

The initial drop in arterial pressure can be a result, for example, ofan activation of parasympathetic or deactivation of the sympatheticsystem. Optionally, it may reflect CGRP secretion, known to be activatedby reno-reno reflex stimulation. Coupled with increased urine flow, GFRand RBF, this result is highly suggestive of inhibition of thesympathetic drive. The stabilization of blood pressure following theinitial drop is probably caused by activation of compensatorymechanisms, most notably the aortic baroreceptors that return the bloodpressure to normal.

Interestingly, we show an increase in RBF during reduced or stablesystemic blood tension. This may mean that stimulation of the ureterselectively dilates the renal vascular bed. Renal selectivity of thedescribed device may make it an attractive option for treating thevarious pathologies in which renal function is impaired and systemicside effects are unwanted.

Example II Acute Results in a Sheep

Effectiveness of electrical stimulation of the ureter was tested on onesheep that underwent nephrectomy 2 month prior to the current procedure.Anesthesia was induced with a mask and halothane (3-4%) in oxygen, thetrachea was intubated, and anesthesia was maintained by ventilating thelungs with halothane (0.5-1%) in a mixture of nitrous oxide and oxygen(3:2). Abdominal cavity was opened by midsagittal incision and theureter was gently exposed near the kidney. Bipolar stimulatingelectrode, made from platinum sheets (contact area of about 1 cm2) wasplaced on the ureter about 10 cm from the kidney the ureter wascatheterized and urine collection was performed for 15 minutes.Stimulation of the ureter increased urine flow by 315%, GFR by 550% andRBF 565%.

FIG. 51 illustrates Urine flow, GFR, and RBF before, during andfollowing ureteral stimulation in a sheep. As can be seen stimulation ofthe ureter drastically improved all these parameters.

The impressive increase in urine flow, GFR and RBF must be consideredwith respect to the low baseline activity of the kidneys. In thisexperiment, the baseline GFR was just 12 ml/min, probably due to thestress of the operation. In this respect this experiment possiblystimulated a condition of developing acute renal failure. The sharpincrease in RBF points to the responsiveness of the renal system tostimulation of the afferent system during condition of increasedsympathetic activation. This result is encouraging, as increased renalsympathetic activity is the hallmark of diverse medical conditions suchas CHF, hypertension, CKD and ARF.

Example III Chronic Results in a Sheep

Using a flank approach, external electrodes were implanted on bothureters, about 5 cm from the renal pelvis. The electrodes were similarto the electrodes used in the acute experiment. They were connected towires that were tunneled subcutaneously to exit at the lumbar region.One week post operation, plasma creatinine level was 1.5 mg/dL, withcorresponding GFR of about 70-80 ml/cc. One month following theoperation the sheep was placed in a metabolic cage for 24 h urinecollection and GFR was estimated by creatinine clearance measurements.Ureteral stimulation was performed by an external pulse generator; thestimulation lasted for 24 h. FIG. 52 shows that Urine flow and GFRincreased during prolonged (24 hour) stimulation of a ureter by animplanted cuff electrode located 5 cm from the kidney pelvis. As can beseen, prolonged elevation of kidney function is possible with long termstimulation. As shown on FIG. 52, the prolonged stimulation improvedurine flow by approximately 25% and GFR by up to 20% relative tocontrol.

In general, during experimentation on sheep, same sheep were used formultiple experiments, sometimes on consecutive days and sometimesnon-consecutive. No reduction in effect was noted.

Example IV

Control of Renal Function with Intravesical Stimulation Device in Sheep

The intravesical stimulator used in these experiments consisted of aspecially designed bladder stimulators with 2 disk shaped platinumelectrodes (electrode diameter 2-5 mm) glued to inflatable balloons of20Fr Foley catheters. The platinum contacts were connected with coatedwires to an external standard laboratory stimulation device (A-Msystems, model 2100). The balloon portion of the catheter was covered bya latex sheath to ease insertion through the urethra. During ballooninflation the sheath is pushed away by the enlargement of the balloon.This arrangement assured a safe, non traumatic insertion of thecatheter.

During the experiments the catheter was positioned so that theelectrodes came into direct contact with the trigone, good electricalcontact was assessed by measuring conductance. When in contact withtissue the conductance ranged 10-1000 Kohm. Resistance of several ohmsor less than 100-800 ohm may indicate shorting by urine. If theelectrodes were in contact with urine the conductance dropped to a fewohms; if the conductance indicated contact with urine the experimentswere stopped and the catheter repositioned till a better location wasfound.

Three healthy female sheep were used in this study; the stimulators wereinserted by a direct visualization of the urethra with a laryngoscope,no sedation was used. Stimulator insertion lasted less than fiveminutes; immediately thereafter the stimulator was connected to a urinecollection bag that was kept below the level of the bladder of theanimal to ensure full emptying of the bladder at all times. During theexperiment, that typically lasted a few hours, the animals were notallowed to drink or eat. This was done in order to reduce thevariability of renal function associated with oral fluid or meal intake.

Urine collection periods were between 30 minutes and one hour.Stimulation was commenced when stable urine production was obtained.Average urine flow was calculated by dividing the volume collected urineby collection time. GFR was analyzed from the following equation:GFR=Ucr×Uvol/Pcr, where Ucr is the urine concentration of creatinine,Uvol is collected urine volume and Pcr is the plasma concentration ofcreatinine. Sodium excretion rate was calculated from multiplication ofurine sodium concentration by the average urine flow.

FIGS. 53A1-53B3 show that Urine flow, GFR, and sodium excretion increase(if any) following stimulation with the stimulator in healthy sheep inthe trigone (FIGS. 53A1-53A3) and in the ventral wall of the bladder(FIG. 53B1-53B3). (* vs control collections; *p<0.05; ***p<0.001; # vstrigone stimulation; #p<0.05; ##p<0.01).

All stimulations started after a steady baseline in urine flow wasreached. Stimulation of the trigone increased urine flow by 33±30%(p=0.01; n=16), GFR by 25±25% (p=0.001; n=15) and sodium excretion by52±32% (p<0.0001; n=14). The effect of trigone stimulation was longlasting, with observable elevations of urine flow to 34±44% (p=0.01) andsodium excretion to 42±73% (p=0.03) in the first collection period (30minutes) following the stimulation.

FIG. 53B shows results, in which a similar device as used for trigonestimulation was inserted into the bladder, but the leads rotated 180degrees to face the ventral part of the bladder, away from the trigone.Stimulation of the ventral part of the bladder did not increase any ofthe parameters of kidney function. During the stimulation urine flow was95±21% of control; GFR was also stable, it increased slightly to 9±15%above control (p=0.37) and sodium excretion was 97±43% of control.Compared to stimulation of the ventral wall, stimulation of the trigonelead to a statistically significant increase in all parameters of renalfunction (p<0.05 for stimulation collection period and half an hour poststimulation for urine flow, GFR and sodium excretion).

Non-direction selective electrical stimulation of the bladder wasexamined in two experiments. The intravesical stimulator used in theseexperiments consisted of a specially designed bladder stimulator with 6disk shaped platinum electrodes glued to an inflatable balloon of a 20FrFoley catheter and distributed evenly on the full circumference of theballoon, 2 cm from the lower part of the balloon (e.g., for stimulatingboth the trigone areas and other areas). Experimental protocol wassimilar as described above.

FIG. 54 shows that Urine flow, GFR and sodium excretion were all reducedduring stimulation. The urine flow was reduced to 66±7.4% of controlvalues (p<0.05), the reduction was significant for at least one hourfollowing the stimulation. Similarly to urine flow, both GFR and sodiumexcretion were reduced for a prolonged time period following bladderstimulation. These findings indicate activation of the vesico-vascularreflex by the stimulation, showing that different reflexes can beactivated by different stimulation locations.

Although the invention has been described in conjunction with specificembodiments thereof, it is evident that many alternatives, modificationsand variations will be apparent to those skilled in the art.Accordingly, it is intended to embrace all such alternatives,modifications and variations that fall within the spirit and broad scopeof the appended claims.

All publications, patents and patent applications mentioned in thisspecification are herein incorporated in their entirety by referenceinto the specification, to the same extent as if each individualpublication, patent or patent application was specifically andindividually indicated to be incorporated herein by reference. Inaddition, citation or identification of any reference in thisapplication shall not be construed as an admission that such referenceis available as prior art to the present invention. To the extent thatsection headings are used, they should not be construed as necessarilylimiting.

1-141. (canceled)
 142. Apparatus comprising: a bladder stimulator thatcomprises: an elongate element adapted to pass through a urethra oradapted to pass through another opening in the bladder; an expandablebody coupled to said elongate element; an array of one or morestimulator contacts coupled to said expandable body, said arrayincluding at least one contact adapted to contact a portion of a bladderof a subject when said expandable body is inserted in the bladder andexpanded; and a controller configured to stimulate the portion of thebladder by driving a pulse into the bladder via the contact, the pulsehaving a frequency of 5 Hz-1 kHz.
 143. The apparatus according to claim142, wherein the controller is configured to drive the pulse, the pulsehaving an energy of between 0.00001 Joule and 0.1 Joule.
 144. Theapparatus according to claim 142, wherein the at least one contact isconfigured to contact a portion of the bladder selected from the groupconsisting of: a trigone, a ureter, a uretero-vesical junction, and adistal portion of a ureter, and wherein the controller is configured tostimulate the selected portion of the bladder.
 145. The apparatusaccording to claim 142, wherein the stimulator is configured to remainin a subject's body for three days to two weeks.
 146. The apparatusaccording to claim 142, wherein the stimulator is configured to beimplanted in a subject's body for at least two weeks.
 147. The apparatusaccording to claim 142, wherein the controller is configured tostimulate the portion of the bladder for at least two hours a day. 148.The apparatus according to claim 142, wherein the controller isconfigured to stimulate an afferent nerve by driving the pulse.
 149. Theapparatus according to claim 142, wherein the controller is configuredto modify the sensitivity of a sensory receptor or a nerve pathwaythereof by driving the pulse.
 150. The apparatus according to claim 142,wherein, by driving the pulse, the controller is configured to modify aphysiological functioning of a tissue that is not directly stimulated bythe controller, said functioning being selected from the groupconsisting of: renal blood flow, GFR, diuresis, and blood pressure. 151.The apparatus according to claim 142, wherein the controller isconfigured to drive the pulse using parameters that are such as to avoidcausing pain to the subject.
 152. The apparatus according to claim 142,wherein said elongate element comprises a tube that defines a lumen andan opening to the lumen, and that is adapted to allow urine flowtherethrough and is configured to substantially evacuate a bladder viathe opening to the lumen of the tube.
 153. The apparatus according toclaim 142, wherein said array covers one hemisphere or less of saidexpandable body, and wherein said array includes fewer than 10stimulator contacts.
 154. The apparatus according to claim 142, whereinsaid contact is expandable with said expandable body.
 155. The apparatusaccording to claim 142, wherein said contact comprises conductingsilicone.
 156. The apparatus according to claim 142, wherein thestimulator is configured to measure urine flow through the elongateelement.
 157. The apparatus according to claim 142, wherein thecontroller is configured to drive the pulse with a sequence suitable forcontrolling a function selected from the group consisting of: a reflex,a cardiovascular function and a kidney function.
 158. The apparatusaccording to claim 142, wherein the stimulator includes a single manualcontrol for adjusting an intensity of effect of said stimulation. 159.The apparatus according to claim 142, wherein said elongate element isflexible.
 160. The apparatus according to claim 159, wherein saidelongate element is soft enough and flexible enough to not interferewith a mobility of a patient when inserted in a urethra thereof. 161.The apparatus according to claim 142, wherein said stimulator isconfigured to facilitate placement of the contact in contact with theportion of the subject's bladder by being shaped to match a distortionof the bladder.
 162. The apparatus according to claim 161, wherein saidstimulator is concave at a point matching a location of an enlargedprostate.
 163. The apparatus according to claim 142, wherein saidstimulator comprises a protecting element configured to prevent damageto a urethra by the contact during insertion of the contact through theurethra.
 164. The apparatus according to claim 163, comprises a coveringsheath.
 165. The apparatus according to claim 142, wherein thestimulator includes a feedback circuit to control said stimulation, saidfeedback including one or both of feedback of a physiological effect ofsaid stimulation and feedback on a quality of contact between saidstimulator contact and tissue of the subject.
 166. A stimulatoraccording to claim 165, wherein the feedback circuit comprises one ormore of an electrical sensor, a flow sensor and a pressure sensor. 167.Apparatus comprising: a bladder stimulator that comprises: a flexibleelongate element adapted to pass through a urethra or adapted to passthrough another opening in the bladder; an expandable body coupled tosaid elongate element; an array of one or more stimulator contactscoupled to said expandable body, said array including at least onecontact adapted to contact a portion of a bladder of a subject when saidexpandable body is inserted in the bladder and expanded; and acontroller configured to stimulate the portion of the bladder by drivinga pulse into the bladder via the contact, the flexible elongate elementdefining a lumen and an opening to the lumen, and being adapted to allowurine flow therethrough and to substantially evacuate the subject'sbladder via the opening to the lumen.
 168. A method of controlling aphysiological state of a subject, comprising: (a) determining that it isdesired to affect functioning of a system of the subject selected fromthe group consisting of: a renal system and a cardiovascular system; and(b) in response thereto, affecting the functioning of the selectedsystem in the desired manner, by stimulating a urine carrying portion ofa urinary system of the subject.
 169. The method according to claim 168,wherein said stimulating comprises modulating a gain of a sympatheticdrive to the kidney.
 170. The method according to claim 168, whereinsaid stimulating comprises modulating activity of an afferent nerveinnervating the urinary system.
 171. The method according to claim 168,wherein said stimulating comprises affecting the functioning of theselected system by performing an action selected from the groupconsisting of: activating and modulating, with respect to at least onenervous reflex.
 172. The method according to claim 168, furthercomprising administering systemic medication to the subject, thestimulating being configured to interact with the administration of themedication to the subject.
 173. The method according to claim 168,wherein said stimulating comprises causing an increase by at least afactor of 1.1 in one or more parameters selected from the groupconsisting of: glomerular filtration rate, renal blood flow, diuresis,and natriuresis.
 174. The method according to claim 168, wherein saidstimulating comprises stimulating one or more portions of the subject'sbody selected from the group consisting of: a ureter, a trigone, auretero-vesical junction, and a bladder.
 175. The method according toclaim 168, wherein said stimulating comprises stimulating via astimulator that remains in the subject's body for three days to twoweeks.
 176. The method according to claim 168, wherein said stimulatingcomprises stimulating via a stimulator that is implanted in thesubject's body for at least two weeks.
 177. The method according toclaim 168, wherein said stimulating comprises treating at leastpartially one or more conditions selected from the group consisting of:acute heart failure, congestive heart failure, hypertension, acute renalfailure, contrast nephropathy, chronic renal failure, shock, septicshock, nephrotic syndrome, cardio-renal syndrome and myocardial infarct.178. The method according to claim 168, wherein said stimulatingcomprises stimulating for at least 2 hours a day.
 179. The methodaccording to claim 168, wherein said stimulating comprises stimulatingin such a manner that the functioning of the selected system is affectedfor at least 30 minutes after stimulation is stopped.
 180. The methodaccording to claim 168, further comprising receiving an input during thestimulation, and modifying a parameter of the stimulation in responsethereto.
 181. The apparatus according to claim 180, further comprisingdetermining a physiological parameter of the subject during thestimulation, wherein receiving the input comprises receiving an inputthat is indicative of the physiological parameter of the subject. 182.The method according to claim 181, wherein determining the physiologicalparameter comprises determining urine flow of the subject during thestimulation, and wherein modifying the parameter of the stimulationcomprises modifying the parameter of the stimulation in response to thedetermined urine flow.